Vascular anatomy of the deep inferior epigastric artery perforator flap: a systematic review.

BACKGROUND: The deep inferior epigastric artery perforator (DIEP) flap is one of the most commonly used perforator flaps for reconstruction. The anatomy of the flap varies considerably between patients and even within patients. The authors conducted a comprehensive review to fully describe the vascular anatomy of the DIEP flap. METHODS: The authors performed MEDLINE, Ovid, and PubMed searches for articles published between 1993 and 2012 on the vascular anatomy of the DIEP flap. Abstracts were screened first, then entire articles, followed by manual reference check. A total of 60 relevant articles were identified and reviewed in their entirety. The authors synthesized all descriptions of DIEP flap vascular anatomy. RESULTS: The perforators originating from the deep inferior epigastric artery can be categorized as musculocutaneous or extramuscular. Musculocutaneous perforators are the most common (33 to 100 percent), followed by extramuscular (0 to 67.6 percent). Of the musculocutaneous perforators, a short intramuscular course (<4 cm) is most common (61 to 80 percent), followed by a long intramuscular course (>4 cm; 9 to 26 percent) and a perpendicular course (3 to 26 percent). Two subfascial patterns have been described, with direct fascial penetration more common than a subfascial course. The two extramuscular perforator types, paramedian (<46.4 percent) and tendinous (<67.6 percent), are the most desirable for dissection. CONCLUSIONS: The vascular anatomy of the DIEP flap shows significant variability. Despite this, several patterns of musculocutaneous and extramuscular-type perforators have been found. A greater understanding of these patterns will improve knowledge of the anatomical variation and will enhance the use of evidence-based perforator selection.

Stacked profunda artery perforator flaps for unilateral breast reconstruction: a case report.

A patient with a severe case of Poland syndrome presented with a painful capsular contracture from a previous implant-based breast reconstruction. She desired the implant to be removed and to proceed with autologous reconstruction, sizeable enough to match the volume of her contralateral breast. A paucity of abdominal donor tissue combined with the patient's hesitancy to acquire an anterior scar excluded this location as a free tissue transfer option. As an alternative donor site, the profunda artery perforator (PAP) flap was chosen. Bilateral PAP flaps were harvested and stacked using anterograde and retrograde anastomoses to the internal mammary vessels. Enough volume was present to fill her chest wall concavity and provide adequate projection to achieve symmetry with her contralateral breast. Her donor sites healed well and remained inconspicuous, without generating difficulties sitting. In conclusion, stacked PAP flaps provide an excellent alternative to an abdominal donor site for achieving large volume unilateral breast reconstruction.

The role of wound healing and its everyday application in plastic surgery: a practical perspective and systematic review.

BACKGROUND: After surgery it is often recommended that patients should refrain from strenuous physical activity for 4-6 weeks. This recommendation is based on the time course of wound healing. Here, we present an overview of incisional wound healing with a focus on 2 principles that guide our postoperative recommendations: the gain of tensile strength of a wound over time and the effect of mechanical stress on wound healing. METHODS: A systematic search of the English literature was conducted using OVID, Cochrane databases, and PubMed. Inclusion criteria consisted of articles discussing the dynamics of incisional wound healing, and exclusion criteria consisted of articles discussing nonincisional wounds. RESULTS: Experiments as early as 1929 laid the groundwork for our postoperative activity recommendations. Research using animal models has shown that the gain in tensile strength of a surgical wound is sigmoidal in trajectory, reaching maximal strength approximately 6 weeks postoperatively. Although human and clinical data are limited, the principles gained from laboratory investigation have provided important insights into the relationship among mechanical stress, collagen dynamics, and the time course of wound healing. CONCLUSION: Our postoperative activity recommendations are based on a series of animal studies. Clinical research supporting these recommendations is minimal, with the most relevant clinical data stemming from early motion protocols in the orthopedic literature. We must seek to establish clinical data to support our postoperative activity recommendations so that we can maximize the physiologic relationships between wound healing and mechanical stress.

Unilateral and Bilateral Breast Reconstruction with Pedicled TRAM Flaps: An Outcomes Analysis of 188 Consecutive Patients.

BACKGROUND: The abdomen remains a popular donor site for autologous tissue breast reconstruction. Recently, however, some authors have questioned whether the pedicled transverse rectus abdominis myocutaneous (TRAM) flap should remain a first-line reconstruction option. METHODS: Between 1998 and 2009, 188 women underwent breast reconstruction with pedicled TRAM flaps by the senior author (J.A.A.). All TRAM flaps involved reinforcement of the abdominal wall repair with polypropylene mesh. Reconstruction was unilateral in 164 patients and bilateral in 24 patients, yielding a total of 212 flaps. RESULTS: The mean follow-up period was 36 months. There were no complete flap losses. Overall hernia rate for the series was 1.6%, and overall abdominal bulge rate was 0.5%. When combining all types of morbidity, 38 unilateral (23.2%) and zero bilateral TRAM flap patients experienced flap site complications (P = 0.005), and 16 unilateral (9.8%) and 5 bilateral patients (20.8%) experienced donor site complications (P = 0.155). For morbidity that required a return to the operating room, the overall rate was 4.3% for unilateral TRAM flap patients and 4.2% for bilateral TRAM flap patients. Flap site morbidity was significantly associated with obesity, former or active smoking, and receiving 2 or more adjuvant therapies. Donor site morbidity was significantly associated with obesity. CONCLUSIONS: The pedicled TRAM flap continues to be an excellent option for breast reconstruction. Complication rates for both unilateral and bilateral TRAM flaps were low in this series, with no complete flap losses and just 4.3% of patients requiring a return to the operating room secondary to morbidity.