Objective To investigate the location of the artery correlated with rectus abdominis musculocutaneous flap in order to promote the reconstruction of the breast after radical mastectocy for breast cancer.Methods An anatomic study was carried out on 15 cadavers of 30 sides，which were immersed in paraformaldehyde less than six months. Whole thoraepigastrica wall was cutted, which scale was from subclavian as upper limit to inguinal ligament, the lower limit across left and right of middle axillary. Veins or arteriesof inferior epigastrica and internal thorax in hang were injected with red or blue ink to show all of vessel branches. Results The external diameters of both the superior epigastric arteries and inferior vessels were 1.87±0.28 mm and 2.25±0.32 mm respectively. The myocutaneous arteries from inferior abdomen vessels had an intensive horizontal distribution on hylum. The perforators significantly decreased but could be found to pass through anterior rectus sheath in Rand. The distances between lateral perforators and Ⅰ,Ⅱ and Ⅲ parts in external edge of anterior rectus sheath were 1.22, 1.46 and1.57 cm, respectively; and the distances between medial perforators and Ⅰ, Ⅱ, and Ⅲ parts at median line were 1.54, 1.62, 1.66 cm. Perforators were more thick and intensive near hylum than in other part. The subcostal arteries derived from inferior abdomen artery and 1.25±0.37 cm away from costal arch. Afterdividing into subcostal artery, the outer diameter of 67 percent of subcostal artery was bigger than that of inferior abdomen arteries. The branches of subcostalarteries were distributed at the 2/3 lateral rectus abdominis, forming an extenive choke anastomosis system with intercostal anterior artery and vessels supplied diaphragmatic muscle. The rectus abdominis at the level of xyphoid was supplied by a branch came from inferoir thorax artery, which diverged epigastric vessels at the same time.Conclusion During the process of makingthe inferior transverse rectus abdominis musculocutaneous flap base on superior epigastric vessels and superoir rectus abdobminis, reservation of pro-theca edge 1 cm of rectus abdominis can protect inferior abdomen artery from injury. Reservation of more than 2 cm pro-theca and rectus abdominis below costal arch at the flag will protect effectively subcostal artery from injury. No damage of subcostal arteries can influence the survival of musculocutaneous flap.
Objective To investigate the results of skinsparing mastectomy and immediate breast reconstruction with transverse rectus abdomins musculotaneous(TRAM) flap or latissimus dorsi musculocutaneousflap plus placement of a mammary implant.Methods From June 1997 to June 2002, 11 patients were proven to have ductal carcinoma in situor huge breast carcinoid by pathological examination. The site of the biopsy incision was around the areola. The patients underwent mastectomy with skin sparing by a circumareolar incision and immediate breast reconstruction withTRAM flap or latissimus dorsi musculocutaneous flap plus placement of mammary implant.Autogenous tissue was used to fill the skin envelop. The second stage operation of nipple-areola reconstruction was performed on the replaced skin.Results Eleven patients were followed up 1 month to 6 years.The operative result was good and all patients had no relapse. The reconstructed breast achieved good results in shape, colour, sensation, symmetry and incision scar. Conclusion The skin sparing mastectomy and immediate autograft tissue breast reconstruction is an ideal reconstructive method for the patients with breast ductal carcinoma in situ or huge breast carcinoid in condition that there were strict operative indication and relapse can be prevented.
Objective To introduce the treatment experiences about the skin-sparing mastectomy and immediate breast reconstruction. Methods The skin-sparing mastectomy and immediate breast reconstruction by using transverse rectus abdominis myocutaneous （TRAM） flat were performed in 10 patients with early-stage breast cancer from May 2008 to December 2011 in our hospital. The patients’ data were retrospectively analyzed. Results There were postoperative complications after skin-sparing mastectomy and immediate breast reconstruction， including TRAM flat necrosis in 1 case， papillary necrosis in 1 case and fat necrosis in the reconstructed breast with oxter wound infection in 1 case. There was no incision hernia of abdominal wall or necrosis of all TRAM flat in any case. The patients’ satisfaction that evaluation for the breast shapes of reconstructed breasts was very satisfaction in 5 cases， part satisfaction in 4 cases， and dissatisfaction in 1 case， respectively. Conclusions Because of the minimal access approach and good breast shape， the skin-sparing mastectomy and immediate TRAM flat breast reconstruction is a safe and effective way for treating early-stage breast cancer.
ObjectiveTo explore the effectiveness of dual-pedicle abdominal flap for unilateral breast reconstruction.MethodsBetween March 2014 and March 2018, a clinical data of 19 female patients underwent dual-pedicle abdominal flap reconstruction because of unilateral mastectomy defect was reviewed retrospectively. The median age was 45 years (range, 32-51 years), including 3 immediate breast reconstruction and 16 delayed breast reconstruction, and left side in 7 cases and right side in 12 cases. Unilateral breast reconstruction were performed for 8 patients with unilateral pedicle transverse rectus abdominis musculocutaneous (TRAM) flap and contralateral free TRAM flap, for 3 patients with pedicle TRAM flap and contralateral deep inferior epigastric perforator (DIEP) flap, for 7 patients with bilateral DIEP flaps, for 1 patient with free muscle-sparing TRAM flap and contralateral DIEP flap. The size of abdominal flap ranged from 24 cm×7 cm to 43 cm×13 cm. The donor sites were closed directly.ResultsVascular crisis ocuurred in 1 flap and relieved after surgical exploration. The other flaps survived. Poor wound healing in abdominal incision occurred in 1 patient and was successfully treated with debridement. The other donor sites healed without any other complication. The patients were followed up with a median period of 12 months (range, 4-42 months). Four patients received reparative operation of their reconstructive breast, and 2 patients received mamopexy of the contralateral breast due to mastoptosis. The abdominal BREAST-Q score was 84.1±11.7, chest score was 86.5±8.9, and breast score was 67.6±16.4 at last follow-up.ConclusionThe dual-pedicle abdominal flap for unilateral breast reconstruction provides adequate soft tissue volume and good blood supply. It is a reliable and effective breast reconstructive method for patients who need large tissue volume to make symmetric with the contralateral breast, or slim patients with few tissue in the donor site, or patients with scars in the donor site, especially vertical abdominal scars.
Objective To investigate if intercostal neurovascular perforator can nourish lower abdominal flap. Methods Between June 2017 and December 2020, in 39 female patients with predominant perforator originated from intercostal nerve nutrient vessels, main trunk of the deep inferior epigastric vessels was chosen to be the pedicle to harvest free lower abdominal flap for breast reconstruction. The age of the patients ranged from 28 to 52 years, with an average of 38.6 years. There were 16 cases on the left and 23 cases on the right. The duration of breast cancer was 3-32 months, with an average of 21.8 months. Pathological stage was stageⅡin 31 cases and stage Ⅲ in 8 cases. Among them, 25 cases were primary tumor resection and one stage breast reconstruction and 14 cases were delayed breast reconstruction. Results The lower abdominal flap pedicled with one side pedicle was harvested in 32 cases, all of which were supplied by the main trunk of the deep inferior epigastric vessel combined with the intercostal neurovascular perforator; 7 cases were harvested with bilateral pedicled lower abdominal flaps, of which 4 cases were supplied by the main trunk of the deep inferior epigastric vessel combined with intercostal neurovascular perforator on one side and deep inferior epigastric artery perforator on the other side, and the other 3 cases were supplied by bilateral main trunk of the deep inferior epigastric vessel and the intercostal neurovascular perforator. In the flaps nourished with the main trunk of the deep inferior epigastric vessel combined with the intercostal neurovascular perforator, the intercostal neurovascular perforators were one branch type in 15 cases, one branch+reticular type in 19 sides, and reticular type in 8 sides. The size of flap ranged from 26 cm×10 cm to 31 cm×13 cm; the thickness was 2.5-5.5 cm (mean, 2.9 cm); the vascular pedicle length was 7.0-11.5 cm (mean, 9.2 cm); the weight of the flap was 350-420 g (mean, 390 g). All the flaps survived completely and the incisions at donor sites healed by first intention. All patients were followed up 14-35 months (mean, 25.4 months). The shape, texture, and elasticity of reconstructed breasts were good and no flap contracture happened. Only linear scar left at the donor site, the function of abdomen was not affected. No local recurrence happened. ConclusionWhen the direct perforator of the deep inferior epigastric artery may not provide reliable blood supply for the lower abdominal flap, the intercostal neurovascular perforator with deep inferior epigastric vessels can ensure the blood supply of the free lower abdominal flap.
ObjectiveTo 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.MethodsBetween 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.ResultsAll 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.ConclusionWhen 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.
ObjectiveTo explore the method of implant coverage with local soft tissue in immediate implant-based breast reconstruction and to evaluate the early effectiveness.
MethodsBetween April 2014 and August 2015, 11 patients with breast cancer underwent immediate breast reconstruction with implants after mastectomy, and the clinical data were reviewed retrospectively. The age ranged 29-48 years (mean, 36 years). The disease duration was from 7 days to 12 months (median, 3 months). According to tumor staging, 3 cases were rated as TisN0M0, 4 cases as T1N0M0, and 4 cases as T2N0M0. The implants were covered with local soft tissue according to the volume of mastectomy and contralateral breast size, including pectoralis major myocutaneous flaps with inframammary adipofasical flaps (3 cases), with serratus anterior fascial flap (5 cases), with rectus sheath fascial flap (1 case), and with serratus anterior fascial flap and rectus sheath fascial flap (2 cases). The size of pectoralis major myocutaneous flaps ranged from 15 cm×9 cm to 20 cm×15 cm, and the serratus anterior fascial flaps from 10 cm×8 cm to 15 cm×10 cm, and the rectus sheath fascial flap from 8 cm×6 cm to 10 cm×8 cm.
ResultsOne patient had partial nipple necrosis postoperatively and was cured, and no other postoperative complications of hematoma, infection, or implant exposure was found. The patients were followed up 4-13 months (median, 8 months). The reconstructive outcomes were excellent in 10 cases and good in 1 case, with an excellent and good rate of 100%. During follow-up, no rupture or exposure of the implant was observed; capsular contracture (Baker grade II) occurred in 1 case.
ConclusionAdequate coverage of implants with different local soft tissue flaps can achieve satisfactory early effectiveness in immediate implant-based breast reconstruction after mastectomy.
ObjectiveTo generalize the application and prospect of computed tomographic angiography (CTA) in deep inferior epigastric artery perforator (DIEP) flap transfer for breast reconstruction.MethodsThe related literature using CTA for DIEP flap reconstruction of breast in recent years was reviewed and analyzed.ResultsPreoperative CTA can accurately assess the vascular anatomy of the chest and abdomen wall, precisely locating the perforator in the abdominal donor site, and identifying the dominant perforator; guide the selection of intercostal space to explore internal mammary artery and internal mammary artery perforator in the chest recipient vessels. It can also reconstruct the volume of the abdominal flap with reference to the size of the contralateral breast and pre-shape the abdominal flap, which are crucial to formulate the surgical plan and improve the reliability of flap.ConclusionPreoperative CTA has enormous application potential and prospects in locating donor area perforator, in selecting recipient vessels, and in evaluating breast volume for autologous breast reconstruction with DIEP flap.
