Muscle-sparing rectus abdominis myocutaneous flap vascularized with intercostal artery perforator and inferior epigastric artery perforator for breast reconstruction_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

SONG Dajiang ¹ ,  LI Zan ¹ , ZHOU Xiao ¹ , ZHANG Yixin ² , FENG Guang ³ , ZHOU Bo ¹ , Lü Chunliu ¹ , WU Peng ¹ , TANG Yuanyuan ¹ , YI Liang ¹ , LUO Zhenhua ¹

1. Department of Oncology Plastic Surgery, Hunan Province Cancer Hospital, Changsha Hunan, 410008, P.R.China;
2. Department of Plastic and Reconstructive Surgery, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200000, P.R.China;
3. Department of Burn and Plastic Surgery, the Fourth Affiliated Hospital of Chinese PLA General Hospital, Beijing, 100048, P.R.China;

Corresponding?author：

LI Zan, Email: zzanli@163.com

Keywords：

Inferior epigastric artery perforator; intercostal artery perforator; free flap; breast reconstruction

DOI：

10.7507/1002-1892.202011020

Video：

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Objective To explore the surgical technique, effectiveness, and safety of muscle-sparing rectus abdominis myocutaneous flap vascularized with intercostal artery perforator and inferior epigastric artery perforator for breast reconstruction.Methods Between December 2016 and February 2019, 6 cases of early breast cancer received modified radical surgery, lower abdominal flap was applied for one- or two-staged breast reconstruction. The average age of the patients was 34.6 years (range, 29-56 years). The disease duration ranged from 2 to 16 months, with an average of 9.5 months. The tumor was located in the upper outer quadrant in 4 cases and the lower outer quadrant in 2 cases. Pathological examination showed that they were all invasive ductal carcinoma. Four cases of breast cancer were in stage Ⅰ and 2 cases was in stage Ⅱ. During operation, the inferior epigastric artery perforators were found to be close to the upper edge of the flap and/or near the umbilical cord in 4 cases, the inferior epigastric artery perforator vessels were relatively small (<0.3 mm) in 2 cases; and the breast was reconstructed with muscle-sparing rectus abdominis myocutaneous flap vascularized with intercostal artery perforator and inferior epigastric artery perforator. The length, width, and thickness of the flap were (28.9±0.2), (12.1±0.4), and (4.4±0.3) cm, respectively. The length of the vascular pedicle was (11.5±0.2) cm and the weight of the flap was (420.5±32.7) g.Results All 6 muscle-sparing rectus abdominis myocutaneous flaps were successful, and the breast incisions healed by first intention. There was no vascular crisis, donor site effusion, hematoma, or infection. All 6 patients were followed up 12-36 months (mean, 26.8 months). The reconstructed breast had a good shape, good elasticity, and no flap contracture or deformation; only linear scars left at the donor site of the flap, and the abdominal wall function was not affected. During follow-up, there was no breast cancer recurrence and metastasis.Conclusion When the inferior epigastric artery perforators are too close to the upper edge of the flap and/or near the umbilical cord, the vascularity of lower abdominal flap can be ruined, harvested in form of muscle-sparing rectus abdominis myocutaneous flap vascularized with intercostal artery perforator and inferior epigastric artery perforator can efficiently ensure blood supply safety.

Citation： SONG Dajiang, LI Zan, ZHOU Xiao, ZHANG Yixin, FENG Guang, ZHOU Bo, Lü Chunliu, WU Peng, TANG Yuanyuan, YI Liang, LUO Zhenhua. Muscle-sparing rectus abdominis myocutaneous flap vascularized with intercostal artery perforator and inferior epigastric artery perforator for breast reconstruction. Chinese Journal of Reparative and Reconstructive Surgery, 2021, 35(5): 605-610. doi: 10.7507/1002-1892.202011020 Copy

1.	Koshima I, Soeda S. Inferior epigastric artery skin flaps without rectus abdominis muscle. Br J Plast Surg, 1989, 42(6): 645-648.
2.	Allen RJ, Treece P. Deep inferior epigastric perforator flap for breast reconstruction. Ann Plast Surg, 1994, 32(1): 32-38.
3.	宋達疆, 劉德權, 李贊, 等. 游離腹壁下動脈穿支皮瓣在雙側乳房再造中的應用. 中華整形外科雜志, 2019, 35(9): 892-897.
4.	Healy C, Allen RJ. The evolution of perforator flap breast reconstruction: twenty years after the first DIEP flap. J Reconstr Microsurg, 2014, 30(2): 121-125.
5.	Koshima I, Inagawa K, Urushibara K, et al. Paraumbilical perforator flap without deep inferior epigastric vessels. Plast Reconstr Surg, 1998, 102(4): 1052-1057.
6.	宋達疆, 李贊, 周曉, 等. 再造乳房術中腹壁下動脈穿支皮瓣切取失敗采用股深動脈穿支皮瓣補救一例. 中華燒傷雜志, 2020, 36(9): 876-879.
7.	宋達疆, 李贊, 周曉, 等. 局部晚期乳腺癌切除術后巨大復雜創面的整形外科修復. 中華整形外科雜志, 2018, 34(8): 630-635.
8.	Rozen WM, Tran TM, Ashton MW, et al. Refining the course of the thoracolumbar nerves: a new understanding of the innervation of the anterior abdominal wall. Clin Anat, 2008, 21(4): 325-333.
9.	Patel SA, Keller A. A theoretical model describing arterial flow in the DIEP flap related to number and size of perforator vessels. J Plast Reconstr Aesthet Surg, 2008, 61(11): 1316-1320.
10.	Grover R, Nelson JA, Fischer JP, et al. The impact of perforator number on deep inferior epigastric perforator flap breast reconstruction. Arch Plast Surg, 2014, 41(1): 63-70.
11.	宋達疆, 彭文, 李贊, 等. 攜帶髂腹股溝淋巴組織瓣的游離腹壁下動脈穿支皮瓣治療乳腺癌根治術后并發上肢淋巴水腫并再造乳房的臨床效果. 中華燒傷雜志, 2019, 35(4): 277-283.
12.	李贊, 宋達疆. 腫瘤性復雜性胸壁缺損的修復策略及對腫瘤治療的積極影響. 中華整形外科雜志, 2020, 36(3): 231-241.
13.	Munhoz AM, Sturtz G, Montag E, et al. Clinical outcome of abdominal wall after DIEP flap harvesting and immediate application of abdominoplasty techniques. Plast Reconstr Surg, 2005, 116(7): 1881-1893.
14.	張興群, 姚毅, 饒磊, 等. 游離帶感覺神經肋間動脈穿支皮瓣移植修復手外傷缺損. 中國修復重建外科雜志, 2020, 34(4): 497-500.

1. Koshima I, Soeda S. Inferior epigastric artery skin flaps without rectus abdominis muscle. Br J Plast Surg, 1989, 42(6): 645-648.
2. Allen RJ, Treece P. Deep inferior epigastric perforator flap for breast reconstruction. Ann Plast Surg, 1994, 32(1): 32-38.
3. 宋達疆, 劉德權, 李贊, 等. 游離腹壁下動脈穿支皮瓣在雙側乳房再造中的應用. 中華整形外科雜志, 2019, 35(9): 892-897.
4. Healy C, Allen RJ. The evolution of perforator flap breast reconstruction: twenty years after the first DIEP flap. J Reconstr Microsurg, 2014, 30(2): 121-125.
5. Koshima I, Inagawa K, Urushibara K, et al. Paraumbilical perforator flap without deep inferior epigastric vessels. Plast Reconstr Surg, 1998, 102(4): 1052-1057.
6. 宋達疆, 李贊, 周曉, 等. 再造乳房術中腹壁下動脈穿支皮瓣切取失敗采用股深動脈穿支皮瓣補救一例. 中華燒傷雜志, 2020, 36(9): 876-879.
7. 宋達疆, 李贊, 周曉, 等. 局部晚期乳腺癌切除術后巨大復雜創面的整形外科修復. 中華整形外科雜志, 2018, 34(8): 630-635.
8. Rozen WM, Tran TM, Ashton MW, et al. Refining the course of the thoracolumbar nerves: a new understanding of the innervation of the anterior abdominal wall. Clin Anat, 2008, 21(4): 325-333.
9. Patel SA, Keller A. A theoretical model describing arterial flow in the DIEP flap related to number and size of perforator vessels. J Plast Reconstr Aesthet Surg, 2008, 61(11): 1316-1320.
10. Grover R, Nelson JA, Fischer JP, et al. The impact of perforator number on deep inferior epigastric perforator flap breast reconstruction. Arch Plast Surg, 2014, 41(1): 63-70.
11. 宋達疆, 彭文, 李贊, 等. 攜帶髂腹股溝淋巴組織瓣的游離腹壁下動脈穿支皮瓣治療乳腺癌根治術后并發上肢淋巴水腫并再造乳房的臨床效果. 中華燒傷雜志, 2019, 35(4): 277-283.
12. 李贊, 宋達疆. 腫瘤性復雜性胸壁缺損的修復策略及對腫瘤治療的積極影響. 中華整形外科雜志, 2020, 36(3): 231-241.
13. Munhoz AM, Sturtz G, Montag E, et al. Clinical outcome of abdominal wall after DIEP flap harvesting and immediate application of abdominoplasty techniques. Plast Reconstr Surg, 2005, 116(7): 1881-1893.
14. 張興群, 姚毅, 饒磊, 等. 游離帶感覺神經肋間動脈穿支皮瓣移植修復手外傷缺損. 中國修復重建外科雜志, 2020, 34(4): 497-500.

Chinese Journal of Reparative and Reconstructive Surgery

Muscle-sparing rectus abdominis myocutaneous flap vascularized with intercostal artery perforator and inferior epigastric artery perforator for breast reconstruction

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