Lumbar Artery Perforator Flaps in Autologous Breast Reconstruction.

The lumbar artery perforator (LAP) flap should be considered for autologous breast reconstruction when a patient's abdomen is unavailable as a donor site. The LAP flap can be harvested with dimensions and volume of distribution that facilitate the restoration of a naturally shaped breast with a sloping upper pole and maximal projection in the lower one-third. Harvest of LAP flaps lifts the buttocks and narrows the waist and, consequently, aesthetic improvement in body contour is generally achieved with these procedures. Although technically challenging, the LAP flap is a valuable tool in the practice of autologous breast reconstruction.

Bipedicle-Conjoined Deep Inferior Epigastric Perforator Flaps for Unilateral Breast Reconstruction in Overweight and Obese Patients: Do the Benefits Outweigh the Risks?

BACKGROUND: Some surgeons have advocated for the use of bipedicle-conjoined deep inferior epigastric perforator (DIEP) flaps in unilateral autologous breast reconstruction in thin patients in whom a hemiabdominal flap is deemed insufficient. There have been no studies to date, however, exploring complication rates for bipedicle-conjoined DIEP flaps for unilateral reconstruction in overweight or obese patients. METHODS: The authors performed a retrospective review of two senior authors' patients from 2013 until 2018. In this time period, 71 patients underwent unilateral breast reconstruction with bipedicle-conjoined DIEP flaps. The patients were divided into normal weight (body mass index [BMI] < 25, n = 30), and overweight/obese (BMI > 25, n = 41) groups. Outcomes were reviewed for both major and minor complications. RESULTS: The average BMI of the normal group was 23.1 ± 1.3 kg/m2, while the average BMI of the overweight/obese group was 28.9 ± 4.0 kg/m2 (p < 0.01). There were no significant differences in demographics or comorbidities between the two groups.There were no statistically significant differences in the overall incidence of major or minor complications between the two groups (major: overweight/obese = 12.1%, normal BMI = 10.0%, p = 0.39; minor: overweight/obese = 39.0%, normal BMI = 36.7%, p = 0.47). The rate of moderate fat necrosis was significantly higher in the overweight/obese group (overweight/obese = 9.8%, normal BMI = 0%, p = 0.04). CONCLUSION: Unilateral breast reconstruction with bipedicle-conjoined DIEP flaps can be performed safely in overweight and obese patients. The use of bipedicle-conjoined DIEP flaps in this population allows surgeons to provide overweight or obese patients with reconstructions that are commensurate with their body habitus and/or contralateral breast.

Unilateral Autologous Breast Reconstruction with Bi-pedicled, Conjoined Deep Inferior Epigastric Perforator Flaps.

BACKGROUND: The abdomen remains the most popular and reliable donor site for autologous breast reconstruction. Some patients, however, lack sufficient tissue to recreate an aesthetic breast mound using a single-pedicle, deep inferior epigastric perforator (DIEP) flap, particularly when matching a contralateral native breast. The amount of abdominal skin and/or soft tissue reliably supplied by one vascular pedicle is frequently insufficient to adequately restore the breast skin envelope and "footprint." This study summarizes our experience with using bipedicled DIEP flaps to improve the aesthetic results of unilateral breast reconstruction in such patients. METHODS: Consecutive patients undergoing unilateral breast reconstruction with bi-pedicled, conjoined DIEP flaps over a 4-year period were retrospectively reviewed. Primary and secondary flap microvascular anastomoses were performed to the antegrade internal mammary (IM) vessels and to either the retrograde IM vessels or a primary DIEP pedicle side branch, respectively. Clinical characteristics and outcomes were recorded. RESULTS: Sixty-three patients underwent immediate (n = 29) or delayed (n = 34) reconstruction, with age and body mass index of 54.1 ± 8.4 years and 26.6 ± 4.7, respectively. Mean follow-up was 14.1 months. Twenty-eight (44.4%) patients received prereconstruction radiation therapy. All patients had preoperative abdominal imaging, including 57 (90.5%) using magnetic resonance angiography. There were no flap losses with three operative interventions for flap salvage. CONCLUSION: Unilateral breast reconstruction with bipedicled, conjoined DIEP flaps is safe and reliable. These procedures can be performed with a complication profile similar to single-pedicle DIEP flaps. The additional skin and soft tissue available with bi-pedicled flaps allows for greater flexibility in matching the shape and projection of a woman's contralateral breast, and in some cases is necessary to achieve an aesthetically acceptable reconstruction. With growing expectations among breast reconstruction patients, conjoined bi-pedicled flaps represent a tool for meeting their reconstructive needs and exceeding the status quo for aesthetic outcomes.

Risk Factors for Postoperative Venous Thromboembolic Complications after Microsurgical Breast Reconstruction.

BACKGROUND: Venous thromboembolism (VTE) is a significant cause of postoperative morbidity and a focus of patient safety initiatives. Despite giving appropriate prophylaxis in accordance with the Caprini risk assessment model, we observed a high incidence of VTE in patients undergoing microsurgical breast reconstruction at our institution. To explore factors contributing to these events, we compared patients undergoing microsurgical breast reconstruction who sustained postoperative VTEs to those who did not. METHODS: A retrospective review of all patients who underwent microsurgical free flap breast reconstruction at Montefiore Medical Center from January 2009 to January 2016 was conducted. Patients were divided into two cohorts; those sustaining postoperative VTE and those who did not. Patients were compared based on demographics, comorbidities, operative time, estimated intraoperative blood loss, need for transfusion, volume of transfusion, and discharge on postoperative aspirin. RESULTS: A total of 133 patients underwent microsurgical breast reconstruction during the study period. Nine patients (6.8%) had postoperative VTE and there was one (0.8%) death. Patients having VTE were more likely to be Hispanic (33.3%, n = 3) in the VTE group versus 8.1% (n = 6) in the control group (p = 0.011), more likely to have an increased mean transfusion volume (455.5 ± 367.8 vs. 139.51 ± 221.7 mL, p = 0.03), and were more likely to be discharged without aspirin (77.8%, n = 7 and 58.1%, n = 72; p = 0.003). CONCLUSION: Patients sustaining postoperative VTE after microsurgical breast reconstruction are more likely to have an increased volume of blood transfusions and lack of discharge on postoperative aspirin.

Breast Tissue Expanders with Magnetic Ports: Clinical Experience at 1.5 T.

BACKGROUND: The purpose of this study was to evaluate breast tissue expanders with magnetic ports for safety in patients undergoing abdominal/pelvic magnetic resonance angiography before autologous breast reconstruction. METHODS: Magnetic resonance angiography of the abdomen and pelvis at 1.5 T was performed in 71 patients in prone position with tissue expanders with magnetic ports labeled "MR Unsafe" from July of 2012 to May of 2014. Patients were monitored during magnetic resonance angiography for tissue expander-related symptoms, and the chest wall tissue adjacent to the tissue expander was examined for injury at the time of tissue expander removal for breast reconstruction. Retrospective review of these patients' clinical records was performed. T2-weighted fast spin echo, steady-state free precession and gadolinium-enhanced spoiled gradient echo sequences were assessed for image artifacts. RESULTS: No patient had tissue expander or magnetic port migration during the magnetic resonance examination and none reported pain during scanning. On tissue expander removal (71 patients, 112 implants), the surgeons reported no evidence of tissue damage, and there were no operative complications at those sites of breast reconstruction. CONCLUSION: Magnetic resonance angiography of the abdomen and pelvis in patients with certain breast tissue expanders containing magnetic ports can be performed safely at 1.5 T for pre-autologous flap breast reconstruction perforator vessel mapping. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

The Lumbar Artery Perforator Flap: 3-Dimensional Anatomical Study and Clinical Applications.

BACKGROUND: The lumbar region is a potential donor site for perforator-based rotational or free flaps or as a recipient site for free flaps to obtain coverage for deficits in the sacral region. Because of the lack of consensus regarding the microvascular anatomy of this potential flap site, a robust investigation of the anatomy of this region is required. METHODS: Three-dimensional reconstructions (n = 6) of the microvasculature of the lumbar region were generated using MIMICS software (Materialise, Belgium) for each of the four paired lumbar vessels. Diameter, course, and pedicle length were recorded for all lumbar artery (LA) perforators. Statistical analysis was performed using SigmaStat 4.0 and graphs were generated using GraphPad Prism 6 Software. RESULTS: Perforators arising from the first pair of LAs are reliably detected along the inferior margin of the 12th rib, extending inferiorly and laterally from the midline while perforators arising from the fourth pair of LA perforate the fascia along a horizontal plane connecting the posterior iliac crests. There are significantly more cutaneous perforators arising from the first (L1) and fourth (L4) pairs of LA than from the second (L2) and third (L3) (mean ± SD: L1, 5.5 ± 1.2; L2, 1.4 ± 0.7; L3, 1.3 ± 0.7; L4, 4.8 ± 1.0; P < 0.05). The average perforator diameter arising from L1 is greater than those arising from L4 (diameter ± SD: L1, 1.2 mm ± 0.2 >L4, 0.8 mm ± 0.2; P < 0.0001). L1 and L4 perforators have longer pedicle lengths than those arising from L2 and L3 (length ± SD: L1, 98.2 mm ± 57.8; L4, 106.1 mm ± 23.3 >L2, 67.5 mm ± 27.4; L3, 78.5 mm ± 30.3; P < 0.05). CONCLUSIONS: Perforators arising from the first and fourth LAs arise in a predictable fashion, have adequate pedicle lengths, and are of suitable diameter to support a perforator flap. We present a case to support the potential use of this flap for microvascular breast reconstruction.

Bipedicle-conjoined perforator flaps in breast reconstruction.

BACKGROUND: For some patients seeking autologous breast reconstruction, there may be insufficient abdominal skin and soft tissue to reconstruct an adequately sized breast. Perfusion from a single-pedicle deep inferior epigastric perforator artery flap has a high degree of variability across the midline, and this further limits perfusion. We have found that bipedicle-conjoined abdominal perforator flaps are a novel and reliable technique for reconstruction in these women, and this study examines our experience. MATERIALS AND METHODS: A retrospective review was performed over a 2-y period of bipedicle-conjoined abdominal perforator flaps in 28 patients. For each reconstruction, the pedicle of one flap was anastomosed to the anterograde internal mammary artery vessels and the pedicle of the second flap to a side branch of the primary flap or the retrograde internal mammary vessels. RESULTS: Mean age and body mass index were 50.2 y (standard deviation, 8.0) and 25.9 kg/m(2) (standard deviation, 2.8), respectively. In total, 15 patients (53.6%) received radiation therapy before surgery. There were no flap losses; fat necrosis was found in one flap (3.2%). The large contiguous skin island of the bipedicle-conjoined deep inferior epigastric perforator flaps allowed for extensive replacement of damaged or absent breast skin when necessary. Aesthetically satisfactory results were achieved in all patients. CONCLUSIONS: Bipedicle-conjoined abdominal perforator flaps represent a novel technique in select patients seeking breast reconstruction. The added complexity was safe and reliable in this series of patients. Compared to unipedicle flaps, the increased skin and volume allow greater flexibility to achieve the desired shape and projection.

Autologous breast reconstruction: preoperative magnetic resonance angiography for perforator flap vessel mapping.

BACKGROUND: Selection of a vascular pedicle for autologous breast reconstruction is time consuming and depends on visual evaluation during the surgery. Preoperative imaging of donor site for mapping the perforator artery anatomy greatly improves the efficiency of perforator selection and significantly reduces the operative time. In this article, we present our experience with magnetic resonance angiography (MRA) for perforator vessel mapping including MRA technique and interpretation. METHODS: We have performed over 400 MRA examinations from August 2008 to August 2013 at our institution for preoperative imaging of donor site for mapping the perforator vessel anatomy. Using our optimized imaging protocol with blood pool magnetic resonance imaging contrast agents, multiple donor sites can be imaged in a single MRA examination. Following imaging using the postprocessing and reporting tool, we estimated incidence of commonly used perforators for autologous breast reconstruction. RESULTS: In our practice, anterior abdominal wall tissue is the most commonly used donor site for perforator flap breast reconstruction and deep inferior epigastric artery perforators are the most commonly used vascular pedicle. A thigh flap, based on the profunda femoral artery perforator has become the second most used flap at our institution. In addition, MRA imaging also showed evidence of metastatic disease in 4% of our patient subset. CONCLUSION: Our MRA technique allows the surgeons to confidently assess multiple donor sites for the best perforator and flap design. In conclusion, a well-performed MRA with specific postprocessing provides an accurate method for mapping perforator vessel, at the same time avoiding ionizing radiation.

Gadofosveset trisodium-enhanced abdominal perforator MRA.

PURPOSE: To compare image quality including the number of perforators visualized, vessel contrast ratios, and vessel sharpness with blood pool and extracellular contrast agents in abdominal perforator flap magnetic resonance angiography (MRA). MATERIALS AND METHODS: Preoperative perforator flap MRA was performed prone on 64 consecutive patients undergoing breast reconstruction (32 receiving 20 mL gadobenate dimeglumine and 32 receiving 10 mL gadofosveset trisodium) on transverse 3D fat-suppressed spoiled gradient echo images using high spatial resolution. Image quality was assessed qualitatively on a 4-point scale. On a computer workstation the number of perforators visualized was counted, arterial, venous, muscle, fat, and abdominal perforator signal intensities were measured to calculate signal intensity and contrast ratios, and vessel sharpness was evaluated. RESULTS: The qualitative image quality score was higher for gadofosveset (2.7) than gadobenate (2.0) and CTA (2.0). The mean number of perforators visualized with gadofosveset was 6.8 on right and 10.4 on left compared to 4.6 on right and 6.6 on left for gadobenate (P < 0.0001). The artery-to-fat contrast ratio was comparable, suggesting the difference was not related to magnitude of enhancement. Perforator-to-muscle contrast ratio was greater for gadofosveset, 2.3, compared to gadobenate 1.5 (P = 0.002). Vessel sharpness was also greater for gadofosveset (P = 0.006). CONCLUSION: Perforator MRA image quality including number of perforators visualized, perforator-to-muscle contrast, and vessel sharpness is higher with gadofosveset trisodium compared with gadobenate dimeglumine.

Contrast-enhanced magnetic resonance angiography.

With technological advances in magnetic resonance angiography (MRA), spatial resolution of 1-mm perforating vessels can reliably be visualized and accurately located in reference to patients' anatomic landmarks without exposing patients to ionizing radiation or iodinated contrast, resulting in optimal perforator selection, improved flap design, and increased surgical efficiency. As their experience with MRA in breast reconstruction has increased, the authors have made changes to their MRA protocol that allow imaging of the vasculature in multiple donor sites (buttock, abdomen, and upper thigh) in one study. This article provides details of this experience with multiple donor site contrast-enhanced MRA.

Perforator flap magnetic resonance angiography for reconstructive breast surgery: a review of 25 deep inferior epigastric and gluteal perforator artery flap patients.

PURPOSE: To evaluate the accuracy of magnetic resonance angiography (MRA) for preoperative mapping of rectus and gluteal muscle perforating arteries prior to autologous flap breast reconstruction. MATERIALS AND METHODS: Preoperative MRA on 25 consecutive patients undergoing perforator artery-based autologous breast reconstruction was performed at 1.5 T using 3D liver accelerate volume acquisition (LAVA) of abdominal or gluteal regions acquired during injection of 20 mL of gadobenate dimeglumine with bolus timing optimized using MR fluoroscopy or SmartPrep. Perforator artery size and coordinates relative to umbilicus or top of gluteal crease on 3D MRA were compared to findings at surgery. Reconstructed breast volume estimates from MRA were also compared to weights at harvesting. RESULTS: In all, 132 perforator arteries were found at surgery to be located within 1 cm of the coordinates measured on MRA and were surgically verified to be suitable for flap perfusion. Surgery verified the arterial course and caliber through the rectus and gluteal muscles visualized on MRA in 48 of 49 arteries. Volume rendering of 3D MRA predicted a breast reconstruction volume with a mean difference of 47 g compared to measurements at harvesting. CONCLUSION: MRA accurately maps rectus and gluteal muscle perforator arteries for preoperative planning of autologous flaps for breast reconstruction.

Anatomic imaging of gluteal perforator flaps without ionizing radiation: seeing is believing with magnetic resonance angiography.

Preoperative imaging is essential for abdominal perforator flap breast reconstruction because it allows for preoperative perforator selection, resulting in improved operative efficiency and flap design. The benefits of visualizing the vasculature preoperatively also extend to gluteal artery perforator flaps. Initially, our practice used computed tomography angiography (CTA) to image the gluteal vessels. However, with advances in magnetic resonance imaging angiography (MRA), perforating vessels of 1-mm diameter can reliably be visualized without exposing patients to ionizing radiation or iodinated intravenous contrast. In our original MRA protocol to image abdominal flaps, we found the accuracy of MRA compared favorably with CTA. With our increased experience with MRA, we decided to use MRA to image gluteal flaps. Technical changes were made to the MRA protocol to improve image quality and extend the field of view. Using our new MRA protocol, we can image the vasculature of the buttock, abdomen, and upper thigh in one study. We have found that the spatial resolution of MRA is sufficient to accurately map gluteal perforating vessels, as well as provide information on vessel caliber and course. This article details our experience with preoperative imaging for gluteal perforator flap breast reconstruction.

Perforator flaps: recent experience, current trends, and future directions based on 3974 microsurgical breast reconstructions.

Perforator flap breast reconstruction is an accepted surgical option for breast cancer patients electing to restore their body image after mastectomy. Since the introduction of the deep inferior epigastric perforator flap, microsurgical techniques have evolved to support a 99 percent success rate for a variety of flaps with donor sites that include the abdomen, buttock, thigh, and trunk. Recent experience highlights the perforator flap as a proven solution for patients who have experienced failed breast implant-based reconstructions or those requiring irradiation. Current trends suggest an application of these techniques in patients previously felt to be unacceptable surgical candidates with a focus on safety, aesthetics, and increased sensitization. Future challenges include the propagation of these reconstructive techniques into the hands of future plastic surgeons with a focus on the development of septocutaneous flaps and vascularized lymph node transfers for the treatment of lymphedema.

Breast reconstruction with deep inferior epigastric artery perforator flap: 3.0-T gadolinium-enhanced MR imaging for preoperative localization of abdominal wall perforators.

PURPOSE: To prospectively evaluate 3.0-T gadolinium-enhanced magnetic resonance (MR) imaging for localization of inferior epigastric artery (IEA) perforators before reconstructive breast surgery involving a deep inferior epigastric perforator (DIEP) flap. MATERIALS AND METHODS: This study was exempt from institutional review board approval, and the requirement for informed patient consent was waived. Data were collected and stored in compliance with HIPAA regulations. Nineteen patients (mean age, 46.3 years) underwent three-dimensional gadolinium-enhanced 3.0-T MR imaging of the abdomen before undergoing DIEP flap breast reconstruction. Up to four of the largest perforators arising from the IEA on each side of the umbilicus were identified. The diameter, intramuscular course, and distance from the umbilicus of each perforator were recorded. One of the marked perforators on each side was labeled "the best" on the basis of an optimal combination of perforator features: diameter, intramuscular course, and location with respect to the flap edges. MR findings were compared with intraoperative findings. The two-tailed Student t test was used to compare the mean diameters of all perforators with the mean diameters of the perforators labeled as the best. RESULTS: There were 30 surgical flaps, and 11 (58%) of the 19 patients underwent bilateral flap dissection. At surgery, 122 perforators were localized, and 118 (97%) of these perforators-with a mean diameter of 1.1 mm (range, 0.8-1.6 mm)-had been identified at preoperative MR imaging. Thirty perforators with a mean diameter of 1.4 mm (range, 1.0-1.6 mm) were labeled as the best at MR imaging. Thirty-three perforators were harvested intraoperatively, and all of these had been localized preoperatively. Twenty-eight (85%) of these 33 perforators were labeled as the best at MR imaging. CONCLUSION: Gadolinium-enhanced 3.0-T MR imaging can be used to accurately localize IEA perforators and to select the optimal perforator to be harvested for DIEP flap reconstructive breast surgery.