Orienting the superficial inferior epigastric artery (SIEA) pedicle in a stacked SIEA-deep inferior epigastric perforator free flap configuration for unilateral tertiary breast reconstruction

Superficial inferior epigastric artery (SIEA) flaps represent a useful option in autologous breast reconstruction. However, the short-fixed pedicle can limit flap inset options. We present a challenging flap inset successfully addressed by de-epithelialization, turnover, and counterintuitive rotation. A 47-year-old woman underwent left tertiary breast reconstruction with stacked free flaps using right deep inferior epigastric perforator and left SIEA vessels. Antegrade and retrograde anastomoses to the internal mammary (IM) vessels were preferred; additionally, the thoracodorsal vessels were unavailable due to previous latissimus dorsi breast reconstruction. Optimal shaping required repositioning of the lateral ends of the flaps superiorly, which would position the ipsilateral SIEA hemi-flap pedicle lateral to and out of reach of the IM vessels. This problem was overcome by turning the SIEA flap on its long axis, allowing the pedicle to sit medially with the lateral end of the flap positioned superiorly. The de-epithelialized SIEA flap dermis was in direct contact with the chest wall, enabling its fixation. This method of flap inset provides a valuable solution for medializing the SIEA pedicle while maintaining an aesthetically satisfactory orientation. This technique could be used in ipsilateral SIEA flap breast reconstructions that do not require a skin paddle, as with stacked flaps or following nipple-sparing mastectomy.

Lentivirus-mediated CDglyTK gene-modified free flaps by intra-artery perfusion show targeted therapeutic efficacy in rat model of breast cancer

Background Free flap-mediated gene therapy in the tumor bed following surgical resection is a promising approach in cancer targeted treatment of residual disease. We investigated the selective killing efficacy of a lentivirus-mediated cytosine deaminase-thymidine kinase (CDglyTK) gene in transplanted breast cancer delivered into a free flap by intra-artery perfusion. Methods Proliferation, apoptosis, and cell cycle of rat SHZ-88 breast cancer cells transfected with a lentivirus-mediated CD/TK gene were measured following treatment with ganciclovir and 5-flucytosine in vitro. A model of residual disease of breast cancer in a rat superficial inferior epigastric artery (SIEA) flap model was used to study the therapeutic potential of a double suicide CD/TK and prodrug system in vivo. Results Killing efficacy of the double suicide CD/TK and prodrug system on SHZ-88 cells was mediated by increased apoptosis and cell cycle arrest at the G1 phase with significant bystander effect. Following recombinant lentivirus transfection of rat SIEA flap by intra-artery perfusion, CD/TK gene expression was limited to the flap, and the volume and weight of transplanted tumors were significantly reduced without observable toxicity. Conclusions SIEA flaps transfected with a lentivirus-mediated CDglyTK gene by intra-artery perfusion effectively suppress transplanted breast tumor growth without obvious systemic toxic effects in rats.

Immediate Unilateral Breast Reconstruction using Abdominally Based Flaps: Analysis of 3,310 Cases

Background The abdomen is the most common area from which tissue is harvested for autologous breast reconstruction. We sought to examine national data to determine the differences in total hospital charges, length of stay (LOS), and early postoperative complications following pedicled transverse rectus abdominis myocutaneous flap (pTRAM), free TRAM (fTRAM), deep-inferior epigastric perforator (DIEP), and superficial inferior epigastric artery perforator (SIEA) flaps. Methods The 2009–2013 Nationwide Inpatient Sample Database was used to identify patients who underwent a unilateral mastectomy and only one type of abdominally based autologous flap (pTRAM, fTRAM, DIEP, and SIEA) during the same hospital admission. Outcomes of interest included total charges, LOS, and complications including revision of vascular anastomosis and hematoma. Results A total of 3,310 cases were identified, corresponding to 15,991 abdominally based unilateral immediate breast reconstructions after standard weighting was applied; 5,079 (31.8%) were pTRAM flaps, 4,461 (27.9%) were fTRAM flaps, 6,206 (38.8%) were DIEP flaps, and 245 (1.5%) were SIEA flaps. The mean total charges for pTRAM, fTRAM, DIEP, and SIEA flaps were $17,765.5, $22,637.6, $25,814.6, and $26,605.2, respectively (p < 0.0001). The mean LOS for pTRAM, fTRAM, DIEP, and SIEA flaps were 96.5, 106.5, 106.7, and 108.9 hours, respectively (p = 0.002). The rates for return to the OR for the revision of a vascular anastomosis for pTRAM, fTRAM, DIEP, and SIEA were 0.0%, 1.72%, 2.66%, and 5.64%, respectively (p < 0.0001). Conclusions There is variation in the total charges, LOS, and early complications between pTRAM, fTRAM, DIEP, and SIEA flap-based breast reconstruction. fTRAM, DIEP, and SIEA flaps incur higher hospital total charges, have longer lengths of stay, and experience more immediate complications compared with pTRAM. Well-designed prospective trials are required to better understand the findings from this study with the inclusion of other critical outcomes such as patient satisfaction, aesthetic results, and long-term outcomes such as abdominal wall morbidity.

BREAST-Q questionnaire: tool for evaluation of quality of life following breast reconstruction with DIEP/SIEA flap

Leczenie raka piersi stanowi ważne zagadnienie dla onkologów i chirurgów plastycznych. Dokonuje się znaczący postęp dotyczący wiedzy i sposobów terapii tego nowotworu. Leczenie niejednokrotnie wymaga rekonstrukcji amputowanej piersi. Współczesne metody są coraz doskonalsze i coraz bardziej dopasowane do potrzeb pacjentki. Jednocześnie obserwowany jest stały wzrost zainteresowania oceną jakości życia po wykonywanych procedurach medycznych. Taki trend obserwowany jest szczególnie w chirurgii plastycznej, gdzie prosta ocena ilości powikłań nie jest wystarczająca. Aby skutecznie pomagać, istnieje potrzeba skrupulatnej oceny leczenia dokonanej przez pacjentki. Celem pracy jest omówienie i przedstawienie zastosowania kwestionariusza BREAST-Q. Pozwala on na ocenę zadowolenia chorej ze zrekonstruowanej piersi, satysfakcji z całego procesu leczenia rekonstrukcyjnego i opieki medycznej. W pracy przedstawiono wyniki badania jakości życia kwestionariuszem BREAST-Q u 20 pacjentek po wtórnej rekonstrukcji piersi płatem DIEP bez usuwania żebra podczas uzyskiwania dostępu do naczyń dawczych. Ocena jakości życia pacjentek służy chirurgowi zajmującemu się rekonstrukcją do analizy swojej pracy. Pozwala na głębsze zrozumienie potrzeb i lepsze doradzanie kolejnym pacjentkom podczas konsultacji przedoperacyjnych. Uzyskane wyniki mogą być też przydatne dla płatnika przy podejmowaniu decyzji odnośnie do poziomu refundacji poszczególnych procedur.