Predicting the Feasibility of Utilizing SIEA Flap for Breast Reconstruction with Preoperative BMI and Computed Tomography Angiography (CTA) Data.

BACKGROUND: Diameters greater than 1.5 mm are considered one of the generally accepted criteria for utilizing superficial epigastric artery (SIEA) flaps for breast reconstruction. However, this standard fails to consider individual differences among patients or deep inferior epigastric perforator (DIEP) perfusion of the same angiosome as the SIEA. This study combined the SIEA system with the DIEP system and explored the relationship between the two systems and body mass index (BMI) to theoretically provide a reference for flap choice in the preoperative surgical plan. METHODS: This study analysed preoperative computed tomography angiography (CTA) data from patients who received systematically postoperative treatment for unilateral breast cancer and were scheduled for breast reconstruction from 2013 to 2018 in our centre. All patients included had no past medical history that might have influenced the diameter of the SIEA, and their CTA data showed the presence of SIEA. RESULTS: Twenty-five females with a mean BMI of 23.6 ± 3.3 kg/m2 were included. A total of 30 hemi-abdomens identified with the SIEA were assessed. The measured mean diameter of the SIEA was 1.63 ± 0.55 mm, showing a highly linear correlation with BMI (r = 0.73, p < 0.001), while the maximum diameter of the deep inferior epigastric perforator (DIEPmax) and the number of dominant perforators originating from the deep inferior epigastric artery (DIEA) were not related to BMI. It was analysed from the equation between the calibre of the SIEA and BMI that when the BMI was greater than or equal to 24 kg/m2, the minimum diameter of the SIEA was at least 1.5 mm; when the BMI was 25 kg/m2, the diameter of the SIEA was, at most, 2.0 mm. Based on the linear correlation described above, we proposed that if the diameter of the SIEA was greater than or equal to 2.0 mm, a BMI ≥ 25 kg/m2 could be fully guaranteed. In terms of the advantageous single pedicle for reconstruction, the ratio of the SIEA diameter to DIEPmax (SIEA/DIEPmax) showed a significant linear correlation with BMI (r = 0.82, p < 0.001), and when the BMI was greater than or equal to 25 kg/m2, the lower limit of its predicted value was above 1.0; in other words, the SIEA diameter was advantageous compared with DIEPmax for the use of a single pedicle. In terms of perfusion, the SIEA system was positively correlated with BMI (p < 0.001), while the DIEP system was not. The difference in perfusion level between the SIEA and DIEP systems showed a positive correlation with BMI (p = 0.001), while the sum of the two systems only tended to be correlated, without statistical significance (p = 0.06). CONCLUSIONS: For patients with a BMI ≥ 25 kg/m2 or an SIEA diameter ≥ 2.0 mm, application of an SIEA flap is theoretically a preferable choice in preoperative surgical planning for breast reconstruction. And the patients should meet two conditions: the first one is the absence of past medical history that might potentially influence the diameter of the SIEA; the second is the presence of the SIEA, which has already been shown by the preoperative imaging data. Through perfusion-related studies, we propose that the SIEA is likely a compensatory vessel that is inclined to present in people with larger BMIs. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Autologous Breast Reconstruction with SIEA Flaps: An Alternative in Selected Cases.

BACKGROUND: The deep inferior epigastric perforator flap has been shown to be a reliable option for autologous breast reconstruction. A further refinement in the transfer of lower abdominal tissue is the superficial inferior epigastric artery (SIEA) flap that does not require any incision of the rectus abdominis fascia or muscle and is superior regarding donor-site morbidity. OBJECTIVES: We conducted a retrospective study to assess reliability and outcomes of autologous breast reconstruction using SIEA flaps. METHODS: We performed autologous breast reconstruction in 1708 patients at our department between 2009 and 2018. Of those, 28 patients that underwent breast reconstruction using a SIEA flap were included for a retrospective chart review. RESULTS: Given an overall flap loss rate of 1.8%, we observed total flap necrosis following a SIEA flap in four patients (13%). All cases were secondary to arterial thrombosis. We further recognized a significant correlation between flap failure and a history of spontaneous deep vein thrombosis (p < 0.0001). There was no statistically significant relationship between flap failure and obesity (BMI > 30 kg/m2;p = 0.9) or flap failure and a history of abdominal operations (p = 0.6). CONCLUSIONS: The SIEA flap provides a reasonable option for autologous breast reconstruction with the great advantage of minimal donor-site morbidity. Nevertheless, its use should be preserved to selected cases with favorable anatomy. We therefore recommend proper patient selection based on preoperative computed tomography angiography, intraoperative clinical evaluation and history of hypercoagulable state. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

[To harvest a SIEA flap instead of a DIEP flap in breast reconstruction: A technical note]. / Prélever un SIEP à la place d'un DIEP en reconstruction mammaire : note technique.

Breast reconstruction by abdominal flap has evolved to ensure minimal donor-site morbidity with the description of Deep Inferior Epigastric artery Perforator flap (DIEP flap). Being of the same thickness and the same surface, the Superficial Inferior Epigastric Artery flap (SIEA flap) does not require, for it harvesting, to open the abdominal fascia or to dissect through the muscles minimizing again donor-site sequelae. However, it is little used because of the variability of its vascularization and a higher failure rate than the DIEP in the literature. We believe that it is reasonable, in some cases, to harvest a SIEA flap instead of DIEP flap in mammary reconstruction. We present a technical note explaining our operative strategy for reliably taking a SIEA when the caliber of the vessels allows.

Intra-arterial injection of human adipose-derived stem cells improves viability of the random component of axial skin flaps in nude mice.

BACKGROUND: Skin flap necrosis is a common postoperative complication in reconstructive surgery. Recent evidence suggests that subcutaneously injected adipose-derived stem cells (ASCs) increase the viability of random skin flaps. Here, we examined whether intra-arterial human ASC administration could improve random component survival of axial skin flaps in nude mice. METHODS: Human ASCs isolated from a healthy volunteer by liposuction were injected into nude mice through the right femoral artery at a low (1 × 103 cells), medium (1 × 104 cells), or high (1 × 105 cells) dose. After ASC infusion, right superficial inferior epigastric vessels were ligated to create unipedicled superficial inferior epigastric artery (SIEA) flap with random extension. RESULTS: Flap survival was higher in mice from all three ASC-treated groups, and particularly the medium-dose group was 30% better, than in the control group. Histological examination demonstrated a significantly higher vascular density in the axial skin flap in nude mice treated with the medium ASC dose than in control mice. PKH26-labeled ASCs were identified in skin flaps of ASC-treated mice; some endothelial cells exhibited positive staining for human HLA-A. Compared to the control group, mice in ASC-treated groups had higher vascular endothelial growth factor levels and lower tumor necrosis factor α, interferon γ, and interleukin-6 levels. CONCLUSIONS: Intra-arterial human ASC administration increased the survival of axial skin flaps by attenuating inflammatory reactions and enhancing neovascularization. Intra-arterial ASC administration might yield a higher rate of these cells and of engraftment in the skin flaps. This approach may have a therapeutic role in increasing flap survival.

Body mass index and abdominal wall thickness correlate with perforator caliber in free abdominal tissue transfer for breast reconstruction.

INTRODUCTION: The aim of the study was to investigate the relationship of BMI and abdominal wall thickness (AWT) with the diameter of the dominant deep inferior epigastric artery perforator (DIEP) as well as DIEA branching pattern in preoperatively performed computed tomography angiography (CTA). PATIENTS AND METHODS: We conducted a retrospective study including all patients undergoing DIEP flap breast reconstruction with available CTAs from November 2013 to April 2018 in our department. The caliber-strongest DIEP was detected after passage of the rectus fascia as well as the superficial inferior epigastric artery (SIEA) and correlated with the AWT 5 cm above and below the umbilicus, lateral at the level of the umbilicus and at the level of the anterior superior iliac spine (ASIS), and with BMI. RESULTS: Seventy-seven patients met the inclusion criteria (age: 47.3 ± 8.9 years). We observed a significant relationship (p < 0.05) between DIEP (mean ∅ = 2.98 mm) and BMI (r = 0.353), the AWT supra- and infraumbilical (r ≥ 0.32), and the AWT lateral at the level of the umbilicus and ASIS (r ≥ 0.25). In addition, there was a highly significant correlation (p < 0.01) between SIEA and BMI (r = 0.389) and between the AWT lateral at the level of ASIS (r ≥ 0.41). CONCLUSION: We demonstrated a correlation of the diameter of the dominant DIEP with both BMI and AWT. Focusing on the diameter, in patients with a high AWT at the level of the ASIS, the SIEA, if present, may represent an alternative therapeutic option.

Contralateral unaffected breast augmentation using zone IV as a SIEA flap during unilateral DIEP flap breast reconstruction.

BACKGROUND: Contralateral breast augmentation during unilateral breast reconstruction is a good option for women with small breasts. In patients with adequate lower abdominal tissues, the deep inferior epigastric perforator (DIEP) flap is often the first choice for unilateral autologous breast reconstruction. We use Zone IV, which is usually excised owing to its insufficient blood circulation, as a superficial inferior epigastric artery (SIEA) flap for contralateral breast augmentation. METHODS: Between October 2004 and January 2016, 32 patients underwent unilateral breast reconstruction using a DIEP flap and an attempted simultaneous contralateral breast augmentation with an SIEA flap. The unilateral DIEP flap attached to the contralateral SIEA flap was split into two separate flaps after indocyanine green angiography. In all patients, ipsilateral internal mammary vessels were used as recipient vessels for DIEP flap breast reconstruction. The SIEA flap pedicle was anastomosed to several branches of the deep inferior epigastric vessels. The SIEA flap was inset beneath the contralateral breast through the midline. RESULTS: Of 32 patients, 27 underwent DIEP flap breast reconstruction and simultaneous unaffected breast augmentation using 25 SIEA or 2 superficial circumflex iliac artery perforator (SCIP) flaps. All DIEP flaps survived, and total necrosis occurred in one SIEA flap. The mean weight of the final inset for DIEP flap reconstruction and SIEA or SCIP flap augmentation was 416 g and 112 g, respectively. CONCLUSIONS: Unilateral DIEP flap breast reconstruction and contralateral SIEA flap breast augmentation may be safely performed with satisfactory results.

Predicting and planning for SIEA flap utilisation in breast reconstruction: An algorithm combining pre-operative computed tomography analysis and intra-operative angiosome assessment.

BACKGROUND: Low flap complication rates and excellent aesthetic outcomes are now commonplace in breast reconstruction. As a result, attention is now being focussed on minimising donor site morbidity. Despite its potential donor site advantages, the superficial inferior epigastric artery (SIEA) flap is often discounted, given concerns about the high flap failure rates. In this study, we present our experience of using the SIEA flap in breast reconstruction and provide an algorithm based on pre-operative computed tomography angiography (CTA) to aid pre-operative planning. METHODS: A retrospective analysis of SIEA flap breast reconstruction cases performed at our unit between 2009 and 2016 was performed and outcomes were assessed. In addition, the patients' pre-operative CTA images were assessed and compared to those of a matched group of patients who underwent deep inferior epigastric artery perforator (DIEP) flap breast reconstruction. RESULTS: Twenty-six patients who underwent SIEA flap breast reconstruction were eligible for inclusion. No flaps were lost. Donor site seroma rate was 20%. The largest SIEA diameter in those who underwent an SIEA flap was significantly larger (p = 0.0001) than in those who underwent DIEP flap breast reconstruction. Significantly more number of patients who underwent SIEA flap breast reconstruction had a SIEA diameter greater than or equal to that of the largest DIEP flap perforator (p = 0.0001) in the group where a DIEP flap was used for breast reconstruction. CONCLUSION: High success rates can be achieved with abdominal flaps based on the superficial vascular system and careful pre- and perioperative assessment of patients.

Indocyanine green-based fluorescent angiography in breast reconstruction.

BACKGROUND: Fluorescent angiography (FA) has been useful for assessing blood flow and assessing tissue perfusion in ophthalmology and other surgical disciplines for decades. In plastic surgery, indocyanine green (ICG) dye-based FA is a relatively novel imaging technology with high potential in various applications. We review the various FA detector systems currently available and critically appraise its utility in breast reconstruction. METHODS: A review of the published English literature dating from 1950 to 2015 using databases, such as PubMed, Medline, Web of Science, and EMBASE was undertaken. RESULTS: In comparison to the old fluorescein dye, ICG has a superior side effect profile and can be accurately detected by various commercial devices, such as SPY Elite (Novadaq, Canada), FLARE (Curadel LLC, USA), PDE-Neo (Hamamatsu Photonics, Japan), Fluobeam 800 (Fluoptics, France), and IC-View (Pulsion Medical Systems AG, Germany). In breast reconstruction, ICG has established as a safer, more accurate tracer agent, in lieu of the traditional blue dyes, for detection of sentinel lymph nodes with radioactive isotopes ((99m)-Technetium). In prosthesis-based breast reconstruction, intraoperative assessment of the mastectomy skin flap to guide excision of hypoperfused areas translates to improved clinical outcomes. Similarly, in autologous breast reconstructions, FA can be utilized to detect poorly perfused areas of the free flap, evaluate microvascular anastomosis for patency, and assess SIEA vascular territory for use as an alternative free flap with minimal donor site morbidity. CONCLUSIONS: ICG-based FA is a novel, useful tool for various applications in breast reconstruction. More studies with higher level of evidence are currently lacking to validate this technology.

Reconstruction of thoracic burn sequelae by scar release and flap resurfacing.

INTRODUCTION: In the USA, 450,000 thermal burns receive medical treatment annually. Burn scars are commonly excised and covered with skin grafts. Long-term, these treatments commonly leave patients with discomfort, reduced total lung capacity and forced vital capacity, and restriction of thoracic expansion and shoulder joint mobility. In this article, we present our experience with using scar release and immediate flap reconstruction to treat thoracic restriction due to burn sequelae. METHODS: From 1998 to 2014, we enrolled 16 patients with anterior thoracic burn sequelae that had previously been treated conservatively or with skin grafts that eventually recidivated. Preoperatively, we measured thoracic circumference in expiration and inspiration, %FVC, %FEV1, and shoulder mobility. All patients underwent anterior thoracic scar release and immediate flap resurfacing. RESULTS: At 2 weeks to 3 months postoperatively (mean, 2.6 months), mean thoracic circumference upon inspiration increased from 83.6 cm±5.7 to 86.5 cm±5.8 (p<0.0000000001). Mean %FVC improved from 76.0%±2.64% to 88.2%±4.69% (p<0.0000001). Mean %FEV1 improved from 79.2%±3.85 to 87.8%±2.98 (p<0.000001). All 14 patients who had restricted shoulder mobility preoperatively no longer had restricted shoulder mobility postoperatively. The mean patient-reported satisfaction was 4.6/5 (range, 3-5). At a mean follow up of 2.5 years, none of the contractures recidivated. Complications included 2 cases of tissue necrosis of the distal end of the flap. In one case, the flap was restored; in the other case, the patient eventually had to receive a new flap. Additional complications included two local infections that were successfully treated with oral and local antibiotics and two hematomas that were drained and eventually healed without tissue loss. CONCLUSIONS: Scar releases and flaps provide a safe and effective method for the correction of restricted thoracic expansion, respiratory restriction, decreased range of shoulder motion, and discomfort from thoracic burn sequelae.

Abdominal perforator vs. muscle sparing flaps for breast reconstruction.

Abdominally based free flaps have become the mainstay for women that desire to use their own tissue as a means of breast reconstruction after mastectomy. As the techniques have evolved, significant effort has been invested in finding the best means of minimizing morbidity to the abdominal donor site while ensuring a viable reconstructed breast that is aesthetically pleasing. This manuscript reviews and compares the muscle sparing free transverse rectus abdominis myocutaneous (MsfTRAM), the deep inferior epigastric artery perforator (DIEP), and the superficial inferior epigastric artery (SIEA) flaps, regarding flap success rate, operative times, abdominal donor site morbidity and residual functionality, hospital lengths of stay and associated costs, impact of co-morbid conditions, and resilience after adjuvant radiation treatment.

Harvesting free abdominal perforator flaps in the presence of previous upper abdominal scars.

PURPOSE: Subcostal scars pose a risk of upper abdominal flap ischaemia when raising a free abdominal flap. The aim of this study was to describe a clinical approach to increase flap reliability and donor site healing in the presence of transverse abdominal scars while harvesting lower abdominal free flaps. METHODS: A total of 11 patients who had subcostal scars and one who had an extended subcostal scar (rooftop or chevron incision) underwent free abdominal flaps for breast reconstruction. Preoperative radiological imaging was used to evaluate the blood supply to the planned flaps. A classification of clinical approaches (I-IV) was used. When the cranial (the abdominal closure) flap width was equal to or greater than half length, a caudal (the breast) flap could safely be harvested (Type I); if not, the cranial flap was enlarged by more caudal flap planning (Type II), an oblique design of the free flap (Type III) or by lowering the free flap marking more distally (Type IV) with a sparing of the peri-umbilical perforators to preserve blood supply to the caudal (abdominal closure) flap. RESULTS: Unilateral free deep inferior epigastric perforator (DIEP) and superficial inferior epigastric artery (SIEA) flaps were successfully harvested in eight and two cases, respectively. In two cases, a bipedicled DIEP/SIEA flap was harvested for unilateral breast reconstruction. Slight abdominal wound slough occurred in one patient; however, no ischaemia resulted in flaps or at donor sites. CONCLUSIONS: Using a pragmatic approach to flap design, based on clinical classification, we have found that both flap and donor site morbidity can be avoided in patients who have previous upper abdominal scars. LEVEL OF EVIDENCE: IV, Therapeutic.

Breast reconstruction with autologous tissue following mastectomy.

Breast cancer remains to be one of the most malignant diseases in the female population. It affects an essential part of female self-consciousness, and therefore causes a wide range of psychological traumas. The incidence in Europe and North America varies between 70 up to 100 new cases in 100.000 inhabitants per year. According to contemporary literature, mastectomy remains one of the most effective methods in the laborious effort to treat and overcome cancer. In this report the history of breast reconstruction is presented. The established methods which are taken into consideration after mastectomy and their clinical outcome are portrayed. The authors propose the free TRAM and DIEP flap as the methods of first choice after mastectomy, which offer most reliable transfer and low morbidity. In the recent past, increasing interest is observed for the SIEA flap. The free S-GAP flap is proposed for patients who are not candidates for a TRAM, DIEP or SIEA flap. Moreover, the pedicled Latissimus Dorsi flap remains still as a reliable, versatile alternative, particularly in case of contraindications for the above mentioned free flaps or when complications occurred.