• Archives of Plastic Surgery
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• v.36 no.6
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• pp.707-713
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• 2009

Purpose: The deep inferior epigastric perforator(DIEP) free flap is well known as an ideal donor site for the breast reconstruction. The flap can provide huge amount of fat tissue for breast and buttock contour, while it is also very useful as a thin skin flap to reconstruct the upper and lower extremities. We used a DIEP free flap in various site reconstructions besides the breast and would like to reinsure the usefulness of this flap. Methods: Twenty nine consecutive patients who underwent DIEP free flap surgery from 2001 January to 2007 December were reviewed. The case constituted seven male patients and twenty two female patients. There were sixteen breast reconstructions, five face reconstructions, five lower extremity reconstructions, two upper extremity reconstructions, and one buttock contour reconstruction. All clinical data were based on the patient's medical records. Results: All DIEP free flaps survived without major complications. There was no hematoma, seroma, or partial necrosis. The donor sites were closed primarily with linear scar on lower abdomen. The thinnest part of flap was 0.7 cm in thickness. The size of the largest flap was $38{\times}13cm$. The flaps were used in various types of skin and adipose tissue, adipose tissue only, and skin only according to the requirement of recipient site. Conclusion: The DIEP free flap was enough to provide a thin and huge flap for both breast and extremity reconstructions. It was able to provide versatile designs with sufficient adipose tissue. So we use it for 3 - dimentional face and buttock contour reconstructions. The DIEP free flap is a valuable reconstructive donor for face, upper and lower extremity in addition to breast without compromising the integrity of abdominal wall.

• Archives of Reconstructive Microsurgery
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• v.22 no.1
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• pp.7-12
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• 2013

Purpose: Breast reconstruction with lower abdominal tissue can produce the best outcome with acceptable rates of long-term complication. However, for cases in which sufficient abdominal tissue is not available, an superior gluteal artery perforator (SGAP) flap can be considered as the next option for autologous breast reconstruction. Materials and Methods: Among a total of 63 women who underwent breast reconstruction with free autologous tissue transfer from July 2010 to April 2011, SGAP flap was performed for four patients. In two cases, patients did not have enough abdominal tissue for sizable breast reconstruction. In another case, the patient had a long abdominal scar due to donor hepatectomy of liver transplantation. In the last case, which was a revisional case after radiation necrosis of a previous pedicled transverse rectus abdominis musculocutaneous (TRAM) flap, a large amount of healthy skin and soft tissue was needed. SGAP flap was elevated in lateral decubitus position. The internal mammary vessels were used for recipient vessels in all cases. Results: Breast reconstruction was performed successfully in all four cases without flap loss. Donor site complication was not observed, except for one case of seroma. The shape of the reconstructed breast was satisfactory in all patients. Conclusion: SGAP flap is an excellent alternative option for the TRAM or deep inferior epigastric artery perforator flap for breast reconstruction. In terms of narrower width, harder consistency of soft tissue, and shorter pedicle, it is clear that the SGAP flap is less competent than the TRAM flap. However, in cases where abdominal tissue is not available, SGAP flap is the only way of providing a large amount of healthy tissue.

• Archives of Plastic Surgery
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• v.50 no.3
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• pp.240-247
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• 2023

More than 40 years have passed since the description of the first "free abdominoplasty flap" for breast reconstruction by Holmström. In the meantime, surgical advances and technological innovations have resulted in the widespread adoption of autologous breast reconstruction to recreate the female breast after mastectomy. While concepts and techniques are continuing to evolve, maintaining an overview is challenging. This article provides a review of current trends and recent innovations in autologous breast reconstruction.

• Archives of Plastic Surgery
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• v.46 no.6
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• pp.599-602
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• 2019

We report a case of autologous breast reconstruction in which a thoracodorsal vessel was used as a recipient vessel after a hypoplastic internal mammary vessel was found on preoperative computed tomography (CT) angiography. A 46-year-old woman with no underlying disease was scheduled to undergo skin-sparing mastectomy and breast reconstruction using a deep inferior epigastric artery perforator flap. Preoperative CT angiography showed segmental occlusion of the right subclavian artery with severe atherosclerosis and calcification near the origin of the internal mammary artery, with distal flow maintained by collateral branches. The thoracodorsal artery was selected to be the recipient vessel because CT showed that it was of adequate size and was not affected by atherosclerosis. The patient experienced no postoperative complications, and the flap survived with no vascular complications. The breasts were symmetrical at a 6-month follow-up. This case highlights that preoperative vascular imaging modalities may help surgeons avoid using diseased vessels as recipient vessels in free flap breast reconstructions.

• Archives of Plastic Surgery
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• v.38 no.4
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• pp.401-407
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• 2011

Purpose: A number of flap for nipple reconstruction have been well described in the literature. However, most of these techniques do not permit the reconstruction of a projecting nipple and all are hampered to some extent by long-term loss of nipple projection. The objective of this study is to evaluate the long-term result and clinical efficacy of nipple reconstruction using skate flap technique after breast reconstruction. Methods: A retrospective chart review was carried out on 23 patients who underwent 25 nipple reconstructions. In those patients with greater than 10 mm nipple projection, reconstruction with skate flap and full-thickness skin graft and/or tattooing was performed. Maintenance of nipple projection was then carefully assessed over one-year follow-up. The following factors were analyzed: type of breast reconstruction, type of areola reconstruction, followup period, decrease in nipple projection, complication, and whether secondary nipple reconstruction was necessary and/or performed. Results: Breast reconstructions were performed in 17 patients with free transverse rectus abdominis musculocutaneous flap, 3 patients with extended latissimus dorsi musculocutaneous flap, and 3 patients with expander and implant. The mean follow-up after nipple reconstruction was 17 months. Mean loss of projection were $17.0{\pm}13.99%$, $25.0{\pm}12.70%$, $30.0{\pm}12.57%$ and $30.8{\pm}12.49%$ at 3, 6, 9 months and over one year, respectively. The greatest decrease in projection was noted in the first 3 months following surgery. Conclusion: These results indicated that nipple reconstruction with skate flap showed about 70 percent of the projection achieved over one year postoperation. Therefore, the skate flap may be a reliable method of nipple reconstruction in those patients with greater than 10 mm nipple projection.

• Archives of Plastic Surgery
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• v.45 no.4
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• pp.333-339
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• 2018

Background Flap volume is an important factor for obtaining satisfactory symmetry in breast reconstruction with a transverse rectus abdominis myocutaneous (TRAM) free flap. We aimed to develop an easy and simple method to estimate flap volume. Methods We performed a preoperative estimation of the TRAM flap volume in five patients with breast cancer who underwent 2-stage breast reconstruction following an immediate tissue expander operation after a simple mastectomy. We measured the height and width of each flap zone using a ruler and measured the tissue thickness by ultrasound. The volume of each zone, approximated as a triangular or square prism, was then calculated. The zone volumes were summed to obtain the total calculated volume of the TRAM flap. We then determined the width of zone II, so that the calculated flap volume was equal to the required flap volume ($1.2{\times}1.05{\times}$the weight of the resected mastectomy tissue). The TRAM flap was transferred vertically so that zone III was located on the upper side, and zone II was trimmed in the sitting position after vascular anastomosis. We compared the estimated flap width of zone II (=X) with the actual flap width of zone II. Results X was similar to the actual measured width. Accurate volume replacement with the TRAM flap resulted in good symmetry in all cases. Conclusions The volume of a free TRAM flap can be straightforwardly estimated preoperatively using the method presented here, with ultrasound, ruler, and simple calculations, and this technique may help reduced the time required for precise flap tailoring.

• Archives of Plastic Surgery
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• v.38 no.5
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• pp.715-717
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• 2011

Purpose: In cases of breast reconstruction with a free transverse rectus abdominis musculocutaneous (TRAM) flap after skin-sparing mastectomy with nipple-areolar complex (NAC) removal, the flat contour of the flap's skin paddle can easily look unnatural and dissatisfying. Reconstructed NAC on the flap surface lacks the elevated contour that the normal areola possesses, resulting in an unnatural final result. Therefore, we would like to introduce a novel method to improve this problem and report the satisfactory results we obtained. Methods: Operations were conducted on 19 patients who underwent immediate breast reconstruction with a free TRAM flap and skin-sparing mastectomy from January 2009 to January 2010, with a mean follow-up of nine months. While the TRAM free flap was being inset, a purse-string suture was carried out on the dermal layer of skin flap to create a slight protrusion with Gore-$Tex^{(R)}$ sutures. Results: The elevated mound surrounding the NAC was well maintained for an average follow-up period of nine months. Nipple projection was also well maintained. There was no complaint about breast contour or nipple height reduction. In addition, there was no reported incidence of other complications. Conclusion: The purse-string suture technique presents a more natural breast silhouette around the NAC and helps to maintain nipple projection. Furthermore, it does not require any supplementary incisions or complicated skills. There has been no report of additional complications using this technique.

• Archives of Plastic Surgery
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• v.38 no.4
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• pp.531-534
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• 2011

Purpose: The rectus abdominis myocutaneous flap is currently the most commonly used donor site of immediate and delayed breast reconstruction surgery, for its versatility and ease of handling, as well as sufficient blood supply. Despite many advantages of rectus abdominis flap, morbidity of donor site is considered as inevitable shortcoming. The authors recently faced a devastating complication, small bowel obstruction that led to strangulation, after delayed breast reconstruction with free transverses rectus abdominis myocutaneous (TRAM) flap. And we would like to report it, because abdominal pain after TRAM flap is a common symptom and can be overlooked easily. Methods: A 56-year-old female patient who had history of receiving total abdominal hysterectomy 20 years ago underwent delayed breast reconstruction with TRAM flap transfer. She complained abdominal discomfort and pain from third postoperative day, postoperative small bowel obstruction that arose from strangulated bowel and prompt emergency operation was done. Results: After resection of the strangulated bowel and reanastomosis, quickly her symptoms were relieved, and there were no further problems during her hospital stay. 7 days after her emergency operation she was discharged. Conclusion: In patients with previous abdominal surgical history, prolonged ileus can lead to bowel strangulation, so surgeons should always consider the possibility, and must be aware of abdominal symptoms in patients who receive free TRAM flap operations.

• Archives of Plastic Surgery
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• v.34 no.2
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• pp.229-236
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• 2007

Purpose: Breast reconstruction with deep inferior epigastric perforator(DIEP) free flap is known to be the most advanced method of utilizing autologous tissue. The DIEP free flap method saves most of the rectus abdominis muscle as well as anterior rectus sheath. Therefore, the morbidity of the donor site is minimized and the risk of hernia is markedly decreased. Methods: We chose the internal mammary artery and its venae comitantes as recipient vessels, and deep inferior epigastric vessels as donor vessels. The number and location of the perforators derived from medial or lateral branch of deep inferior epigastric artery(DIEA) in 23 DIEP flaps were identified. Ten patients underwent evaluation of their abdominal wall function preoperatively and 6 months postoperatively by using Lacote's muscle grading system. Results: Of the 23 patients, a patient with one perforator from lateral branch of DIEA experienced partial necrosis of flap. Total flap loss occurred in one patient. Mild abdominal bulging was reported in one patient 4 months postoperatively probably because of early vigorous rehabilitational therapy for her frozen shoulder. Postoperative abdominal wall function tests in 10 patients showed almost complete recovery of muscle function upto their preoperative level of upper and lower rectus abdominis and external oblique muscle function at 6 months postoperatively. All patients have been able to resume their daily activities. Conclusion: The breast reconstruction with DIEP free flap is reliable and valuable method which provide ample soft tissue from abdomen without compromising the integrity of abdominal wall. Selection of reliable perforators is important and including more than two perforators may decrease fat necrosis and partial necrosis of flap.

• Archives of Plastic Surgery
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• v.32 no.4
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• pp.408-415
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• 2005

Following a transverse rectus abdominis musculocutaneous(TRAM) flap breast reconstruction, denervated state of the flap causes the flap skin prone to thermal injury, calling for special attention. During the last 5 years, 69 breast reconstruction with 72 free TRAM flaps, were performed. Four out of thesse 69 patients sustained burn injury. Heat sources were a warm bag(n=2), heating pad(n=1) and warming light (n=1). The thermal injuries occured from 2 days to 3 months following the reconstruction. Three patients healed with conservative treatment, but one patient required debridement and skin graft. Initially 3 out of 4 patients with the burn had shown superficial 2nd degree burn with small blebs or bullae. However all 4 patients healed with scars. Mechanism of burn injuries of the denervated flap are known to be resulting from; 1) loss of behavioral protection due to denervation of flap with flap elevation and transfer, 2) loss of autonomic thermoregulatory control with heat dissipation on skin flap vasculature contributing to susceptibility of burn injury. 3) changes of immunologic and normal inflammatory response increasing thromboxane, and a fall in substance P & NGF (nerve growth factor). Including the abdominal flap donor site, sensory recovery of the reconstructed breast varies individually from 6 month even to 5 years postoperatively. During this period, wound healing is delayed, resulting in easier scarring compared to that observed in the sensate skin. Patients should be carefully informed and warned of possible burn injuries and taught to avoid exposure to heat source at least until 3 years postoperatively.