The deep inferior epigastric artery perforator flap for autologous reconstruction of large partial mastectomy defects

BACKGROUND:: Breast conservation surgery in the treatment of early stage breast cancer has become increasingly utilized as a means to avoiding mastectomy. While partial mastectomy defects (PMDs) may often be cosmetically acceptable, some cases warrant consideration of reconstructive options, and while several reconstructive options have been described in this role, a series of deep inferior epigastric perforator (DIEP) flaps has not been reported to date. METHODS:: A cohort of 18 patients undergoing PMD reconstruction with a DIEP flap were included. Patient-specific data, operation details, cosmetic results, and complication rates were assessed. Oncologic outcomes, in particular recurrence rates, were also evaluated. RESULTS:: In our series there were no cases of partial or total flap necrosis, and overall complications were low. There were two cases of wound infection (both had undergone radiotherapy), managed conservatively, and one case of reoperation due to hematoma. There were no cancer recurrences or effect on oncologic management. Cosmetic outcome was rated as high by both patients and surgeon. The results were thus comparable with other reconstructive options. CONCLUSION:: Although autologous reconstruction has an established complication rate, our results suggest that the DIEP flap may be of considerable value for delayed reconstruction of selected larger partial mastectomy defects. (c) 2010 Wiley-Liss, Inc. Microsurgery, 2010

Perineal and posterior vaginal wall reconstruction with superior and inferior gluteal artery perforator flaps

Perineal and posterior vaginal wall reconstruction following abdominoperineal and local cancer resection entails replacement of volume between the perineum and sacrum and restoration of a functional vagina. Ideal local reconstructive options include those which avoid functional muscle sacrifice, do not interfere with colostomy formation, and avoid the use of irradiated tissue. In avoiding the donor site morbidity of other options, we describe a fasciocutaneous option for the reconstruction of the perineum and posterior vaginal wall. We present our technique of superior and inferior gluteal artery perforator (SGAP or IGAP) flaps to reconstruct such defects. Fourteen patients between 2004 and 2008 underwent 11 SGAP and three IGAP flaps. There were no flap failures or partial flap losses and no postoperative hernias. All female patients reported resumption of sexual intercourse following this procedure. Our experience in both the immediate and delayed setting is that this technique produces a good functional outcome with low donor-site morbidity

Autologous microsurgical breast reconstruction and coronary artery bypass grafting: an anatomical study and clinical implications

OBJECTIVE: To identify possible avenues of sparing the internal mammary artery (IMA) for coronary artery bypass grafting (CABG) in women undergoing autologous breast reconstruction with deep inferior epigastric artery perforator (DIEP) flaps. BACKGROUND: Optimal autologous reconstruction of the breast and coronary artery bypass grafting (CABG) are often mutually exclusive as they both require utilisation of the IMA as the preferred arterial conduit. Given the prevalence of both breast cancer and coronary artery disease, this is an important issue for women's health as women with DIEP flap reconstructions and women at increased risk of developing coronary artery disease are potentially restricted from receiving this reconstructive option should the other condition arise. METHODS: The largest clinical and cadaveric anatomical study (n=315) to date was performed, investigating four solutions to this predicament by correlating the precise requirements of breast reconstruction and CABG against the anatomical features of the in situ IMAs. This information was supplemented by a thorough literature review. RESULTS: Minimum lengths of the left and right IMA needed for grafting to the left-anterior descending artery are 160.08 and 177.80 mm, respectively. Based on anatomical findings, the suitable options for anastomosis to each intercostals space are offered. In addition, 87-91% of patients have IMA perforator vessels to which DIEP flaps can be anastomosed in the first- and second-intercostal spaces. CONCLUSION: We outline five methods of preserving the IMA for future CABG: (1) lowering the level of DIEP flaps to the fourth- and fifth-intercostals spaces, (2) using the DIEP pedicle as an intermediary for CABG, (3) using IMA perforators to spare the IMA proper, (4) using and end-to-side anastomosis between the DIEP pedicle and IMA and (5) anastomosis of DIEP flaps using retrograde flow from the distal IMA. With careful patient selection, we hypothesize using the IMA for autologous breast reconstruction need not be an absolute contraindication for future CABG

Self-esteem and patients' satisfaction after deep inferior epigastric perforator flap breast reconstruction

The objective of this article is to assess the impact of deep inferior epigastric perforator (DIEP) flap breast reconstruction on self-esteem and to analyze the correlation between aesthetic outcome and self-esteem. Global self-esteem was evaluated using the Rosenberg Self-Esteem Scale in 31 patients who underwent DIEP flap breast reconstructions. A study-specific questionnaire and photographic evaluation were used by the patient, the plastic surgeon, and the oncological surgeon to measure satisfaction with the aesthetic outcome. Patients' satisfaction and self-esteem were analyzed for any existing correlation. Overall patients' satisfaction had a mean score of 6.55 (range, 0-10) on the Patient Satisfaction Questionnaire. A mean score of 32.48 (range, 10-40) was found on the Rosenberg Self-Esteem Scale. More than 80% of patients were content with their decision to undergo this procedure and would recommend this to a friend. Surgeons tended to rate the aesthetic outcome better than patients. Patients' satisfaction and self-esteem were found to be positively correlated. Patients are generally content with the outcome of primary DIEP flap breast reconstruction. The favorable aesthetic result of this procedure has a beneficial effect on patients' self-esteem