|
History and an update on current technique
Jay W. Granzowa, Joshua L.
Levineb, Ernest S. Chiub
and Robert J. Allen
aUCLA Division of Plastic and Reconstructive
Surgery 200 UCLA Medical Plaza, Suite 465 Los Angeles, CA 90095-6960,
USA
bSection of Plastic Surgery, Louisiana
State University Health Sciences Center, 4429 Clara Street, Suite
440, New Orleans, LA 70115, USA
Received 18 May 2005; accepted 1 January 2006. Available online
20 March 2006.
Summary
Perforator flaps allow the transfer of the patient's own skin
and fat in a reliable manner with minimal donor site morbidity.
For breast reconstruction, the abdomen typically is our primary
choice as a donor site. The deep inferior epigastric perforator
(DIEP) flap remains our first choice as an abdominal perforator
flap and has become a mainstay for the repair of mastectomy defects.
It allows the transfer of the same tissue from the abdomen to the
chest for breast reconstruction as the TRAM flap without sacrifice
of the rectus muscle or fascia. We discuss our current techniques
and specific issues related to the surgery. We present the results
of 1095 cases of free tissue transfers from the abdomen for reconstruction
of the breast.
Keywords:
Breast reconstruction; Perforator flap; Microsurgery; DIEP;
SIEA
Article Outline
Indications
Anatomy
Current surgical technique
Postoperative care
Total number of patients
Discussion
References
Breast reconstruction is a vital component of the overall
treatment plan of breast cancer patients. Surgical breast
reconstruction is not only desired by most patients, but
is recommended by law in many countries. It is being performed
with increasingly sophisticated techniques to optimise the
appearance, and feel of the reconstructed breast limit donor
site morbidity and provide a long term result. The use of
autologous tissue allows the reconstruction of a breast
which looks and feels most like a normal breast. The advent
of perforator flaps now allows for minimal donor site morbidity
and good flap durability.
The abdomen is an ideal source of tissue for breast reconstruction.
Most patients who develop breast cancer are at an age when they
also have excess skin and fat overlying the abdomen. The fat is
typically soft and easy for the surgeon to shape and closely approximates
the feel of a normal breast. In addition, an added bonus of an abdominal
donor site for most patients is the improved abdominal contour after
flap harvest which approximates that of an abdominoplasty or 'tummy
tuck' while minimising donor site morbidity.
The deep inferior epigastric perforator (DIEP) flap is
a central component in the state-of-the-art practice of
breast reconstruction and usually our first choice of flap
from the abdomen. It allows the safe transfer of soft tissue
from the abdomen for the construction of a new breast without
the sacrifice of rectus muscle or fascia.
The DIEP and other perforator flaps trace their origins
back to the work of Stuart Milton in the 1960s. At that
time, wound closure flaps were random pattern flaps based
on the geometric principle of a length to width ratio of
approximately 1.5–1. Using a porcine model, Dr Milton
in 1970 and 1971 demonstrated that flaps of a much greater
length to width ratio could be elevated safely when based
on a known underlying vessel.1
and 2
This led to the concept of the axial pattern pedicle flap,
which was first reported in MacGregor and Jackson's description
of a groin flap in 1972.3
Later, in 1982, Hartrampf would use the pedicle flap concept
to transfer abdominal tissue to the chest for breast reconstruction
using the superior epigastric artery and the rectus abdominus
muscle as a carrier.4
This flap came to be known as the transverse rectus abdominus
myocutaneous, or TRAM, flap.
In 1973, the term 'free flap' was used by Taylor
and Daniel to describe the distant transfer of an island flap by
microvascular anastomosis.5
and 6 Taylor
and Daniel further expanded upon their work in 1975 with a detailed
anatomical description of many of the more common free flap donor
sites in use today.7
In 1979, Holstrom described the use of the equivalent of a free
TRAM flap with his description of a “free abdominoplasty flap”
for breast reconstruction.20
Attempts were made to reduce the muscle bulk removed and
to limit the donor morbidity.8
The concept of donor site muscle sparing techniques was
reported, as represented by Elliott with the split latissimus9
and by Feller with the partial rectus abdominus muscle transfer.10
This idea was further refined by Koshima who used the skin
territory overlying the rectus abdominus muscle for reconstruction
of the mouth and groin.11
The flaps were based on a single paraumbilical perforating
vessel from the deep inferior epigastric artery, and were
composed of skin and fat only.
Independently, Allen and Treece in 199212
successfully performed the first DIEP flap for breast reconstruction
by transferring the abdominal skin and fat from the same
donor area of a TRAM flap while sparing the underlying rectus
abdominus muscle. This provided essentially the same soft
tissue for reconstruction while significantly reducing the
morbidity to the abdominal wall, thereby minimising donor
site morbidity and pain while shortening recovery time.13,
14
and 15
Indications
Most women who have had or will have mastectomies
for breast cancer are possible candidates for a DIEP flap. In
addition, this flap may be used for women requiring additional
breast tissue for reconstruction of defects such as a congenital
breast deficiency, a lumpectomy defect or for autologous breast
augmentation.16
Absolute contraindications specific to abdominal perforator
flap breast reconstruction in our practice include history
of previous abdominoplasty or abdominal liposuction, or
active smoking (within 1 month prior to surgery). Relative
contraindications include large transverse or oblique abdominal
incisions. Care must be taken in patients with previous
appendectomy scars. In our practice, we have encountered
a case where the right deep inferior epigastric artery pedicle
had been divided during the patient's appendicectomy many
years previously.
We prefer to have the patient complete any radiation therapy
to the chest prior to surgical breast reconstruction. While
the perforator flaps usually tolerate radiation well, a
superior long-term result is obtained typically in reconstructions
performed after rather then before chest wall radiation.
This spares the flap the damaging effects of radiation and
allows the replacement of any thick and stiff irradiated
chest wall skin and its replacement with soft and unirradiated
abdominal skin and soft tissue.17
Anatomy
Like a TRAM flap, the DIEP flap is based on the deep inferior
epigastric artery and vein. Two rows of perforating arteries and
veins penetrate the rectus muscle on each side of the abdomen
to provide the blood supply for the overlying skin and fat (Fig.
1). The deep inferior epigastric artery is typically between
2 and 3 mm in diameter and the accompanying veins are between
2 and 3.5 mm in size.
Figure 1.Typical preoperative marking on the lower
abdomen of a patient undergoing breast reconstruction
using the DIEP free flap.
In contrast to a TRAM flap, however, no rectus muscle or
fascia must be sacrificed. Instead, the perforating vessels,
which supply the overlying skin and fat are carefully followed
through the rectus muscle to their origins from the deep
inferior epigastric vessels. The rectus muscle itself is
spared and atraumatically spread apart in the direction
of the muscle fibres during the dissection (Fig.
2).The internal mammary or thoracodorsal vessels are
used as recipient vessels (Figure 3
and Figure 4).
Figure 2.Perforating vessels of the lateral branch
of the deep inferior epigastric artery are visible coursing
through the rectus sheath.
Figure 3.Isolation of the internal mammary artery
provides an excellent recipient site.
Figure 4.Recipient and flap arteries after anastomosis
and flap inset.
Current surgical technique
The patient is seen in the office one day prior to surgery.
The surgical plan is reviewed with the patient, and any
remaining questions are answered.
Standard abdominoplasty markings are made in the sitting
or standing position. The side of the abdomen contralateral
to the side to be reconstructed is preferred, as this provides
for a synchronous two team approach. Because a very long
pedicle may be harvested, insetting typically is not a problem
with either an ipsilateral or contralateral pedicle. Flaps
are marked approximately 12 cm high at the midline
and extend approximately 22–24 cm laterally
from the midline. Then, with the patient in a supine position,
a hand held audible Doppler probe is used to identify the
main perforators of the medial and lateral branches of the
deep inferior epigastric artery. The superficial inferior
epigastric artery and vein are likewise located with the
Doppler probe and marked.
The side of the abdomen contralateral to the side to be
reconstructed is preferred. We prefer to use the thicker
medial and paraumbilical abdominal fat for reconstruction
of the inferomedial breast with the lateral part of the
flap inset towards the axilla. A DIEP flap based on multiple
perforators will have a pedicle which naturally will lay
best toward the internal mammary recipient site in a contralateral
flap. If the thoracodorsal vessels are used as recipients,
the geometry of an ipsilateral DIEP flap would be advantageous.
However, most ipsilateral or contralateral DIEP flaps can
be inset without difficulty in either case because the long
length of the vascular pedicle allows significant freedom
in flap insetting.
On the chest, the midline and the inframammary crease on
both sides are marked. For patients undergoing immediate
breast reconstruction, suggested skin markings for the surgical
oncologist are drawn on the breast, which include marks
around the nipple areolar complex and previous biopsy site.
For patients with large breasts, a pattern is marked which
is similar to those of a vertical scar breast reduction.
For patients with smaller breasts, a circle around the nipple
areolar complex with a small inferior or lateral extension
may suffice (Figure 5 and Figure
6).
Figure 5.(A) Preoperative markings for patient
with right breast carcinoma. (B) DIEP flap raised on perforator.
(C) DIEP flap after harvest. (D) Patient 3 months after
initial flap transfer. (E) Patient 3 months after nipple
construction.
Figure 6.(A) and (B) Preoperative views of patient
with right breast carcinoma for mastectomy with DIEP flap
reconstruction. (C) and (D) Patient approximately 3 months
following second stage procedure, nipple reconstruction
and areolar tattoo.
The operating room table is turned 180° to allow the
surgeons to sit comfortably with legs under the table during
the microvascular anastomosis. Under general anaesthesia,
the patient is prepped and draped from the chin to the upper
thighs. The ipsilateral arm may be prepped and included
in the field if an immediate sentinel node biopsy or axillary
node dissection is to be performed in addition to the mastectomy.
For an immediate breast reconstruction, dimensions and weight
of the mastectomy specimen are recorded.
A two team approach is used, with simultaneous raising
of the flap and preparation of the recipient vessels. The
internal mammary artery (IMA) and vein (IMV) are used in
over 90% of our cases while the thoracodorsal vessels are
our second choice. The internal mammary vessels are noted
to be of good quality and calibre in most cases. We use
the thoracodorsal vessels, which are typically not as robust,
for reasons of flap geometry or ease of flap insetting rather
than insufficiency of the internal mammary vessels.
We approach the IMA in the second or third interspace.
Occasionally, a large perforating artery and vein from the
internal mammary vessels may be found and these vessels
used as the recipients in the chest. The IMA and IMV are
usually between 2.5 and 3 mm in size. Sometimes a second
vein between 1.5 and 3 mm may be encountered. In the
case in the narrow interspace, a small portion of the rib
cartilage above and below may be removed for better exposure
and insetting of the pedicle.
When we perform a DIEP flap, the superior and inferior
skin incisions are made and the superficial inferior epigastric
vessels are first approached. If these are found to be of
significant size and quality, they are followed down to
their origin from the superficial femoral artery and an
SIEA flap is performed instead. Often only the superficial
inferior epigastric vein is present of sufficient size and
this is dissected free for several centimetres. This can
be used as a backup for the venous drainage of the flap
if venous congestion be present after the anastomosis is
performed in the chest. In our experience, this vein can
prove invaluable in the rare case where congestion is present
due to insufficient drainage through the deep system.
The abdominal skin island is carefully elevated from lateral
to medial until the lateral row of perforators is encountered.
The lateral perforators are carefully inspected. If a large
lateral perforator is found, the flap may be based on this
vessel. Additional perforators in the same row may also
be dissected and included with the flap for additional perfusion.
If no large lateral row perforators are found, the medial
row is approached in a similar fashion. If no dominant single
perforators are found, two or more smaller perforators in
the same lateral or medial row may be taken to perfuse the
flap. In cases where more than one large perforator is present,
the perforator with a more central location to the proposed
flap is utilised. In our experience, approximately 25% of
flaps are based on one perforator, 50% on two perforators
and 25% on three or more perforators.18
Once the appropriate perforators are chosen, the anterior
rectus sheath is opened around the perforators and the vessels
are carefully dissected down through the rectus muscle to
the deep inferior epigastric artery and vein. The muscle
is spread apart in the direction of the fibres and care
is taken to identify and preserve any intercostal nerves
innervating the medial aspect of the muscle, which might
cross the pedicle. Dissection continues until the pedicle
is of sufficient length, typically eight to 10 cm long,
and the vessels are a sufficient caliber to match the recipient
vessels in the chest. High power loupe magnification and
careful microsurgical technique are essential during this
dissection.
Pure sensory nerves which innervate the flap skin paddle
typically run with the perforators and may also be dissected
free for anastomosis into divided recipient sensory nerves
in the chest.
Once the recipient vessels are ready, the anterior surface
of the pedicle vessels at their origin are marked with a
surgical marker for pedicle orientation in the chest. The
artery and then veins of the pedicle are ligated and the
pedicle slid out underneath any crossing intercostal nerves.
The flap is then weighed and transferred to the anterior
chest wall. Great care is taken to lay the pedicle of to
the recipient vessels without any twists or kinks in the
vessels. While vascular problems with the flaps occur rarely,
many of the venous difficulties that do occur result from
a twist or a kink of the pedicle. Temporary stay sutures
are placed in the flap and the operating microscope is brought
into position.
Under magnification, the anterior surface of the recipient
artery and vein are also labelled with a surgical marker
and the larger vein is ligated distally. An anastomotic
coupling device is used to connect to the recipient and
flap veins (Microvascular Anastomotic COUPLER System, Synovis,
www.synovismicro.com). A coupling device makes the anastomosis
easier and faster, and has the additional benefit of stenting
the vein open after the vessels are joined. Typically, the
arterial anastomosis is performed with a nylon 9/0 suture.
In the case of a good size match between the flap and recipient
arteries, a running suture is employed. Otherwise, interrupted
9/0 or 10/0 nylon sutures are used. After the anastomosis
is complete, the flap is checked for bleeding and capillary
refill. In the case of a small skin island or in a patient
with dark skin where skin evaluation may be difficult, an
implantable Doppler probe (Cook-Swartz Doppler Flow Probe;
Cook Vascular Incorporated, www.cookvascular.com) is used
to monitor a continuous arterial and/or venous signal.
The abdominal fascia is closed and securely tied with running
size 0 PDS suture. Mesh or other synthetic materials are
not required for the abdominal wall closures. The edges
of the umbilicus are tacked down to the fascia with 2/0
Vicryl suture. The upper abdominal flap is elevated, the
patient flexed and the wound closed in layers over two closed
suction drains. Care is taken to approximate Scarpa's fascia
with 2/0 interrupted Vicryl sutures. As in an abdominoplasty,
the umbilicus is brought out through the abdominal flap
and secured in place.
The flap is typically inset with the narrower and more
lateral portion of the flap placed up towards the axilla
and the thicker, more medial aspect of the flap placed inferiorly
and medially. The flap can be further medialised and kept
from falling laterally into the axilla by suturing the superior
and lateral most parts of the flap to the lateral portion
of the pectoralis major muscle. The flap may also be folded
under itself inferiorly to provide more natural looking
inferior ptosis and fullness for the reconstructed breast.
The insetting and closure are performed over a suction drain
and great care is used to monitor the integrity of the pedicle
during the insetting at the flap at all times. Excess skin
is deepithelialised and the flap inset with a visible skin
paddle left in place.
During the insetting, all of zone 4 is typically removed,
weighed and discarded. We find that the perfusion from a
perforator flap usually is sufficient only to carry zones
1–3. Areas of significant or palpable fat necrosis
occur in a minority of cases only and these are addressed
during the standard second stage revision.
Postoperative care
Postoperatively, the patient is observed in the Surgical Intensive
Care Unit overnight and transferred to the ward in the morning
of the first postoperative day. As the postoperative pain is significantly
less than with a TRAM flap reconstruction,15
usually oral analgesics are given 1st postoperative day onwards.
The patient ambulates on 1st postoperative day and is discharged
home on 4th postoperative day.
A second stage revision and nipple creation are performed
under local anaesthesia with intravenous sedation in the
operating room between 8 and 12 weeks after the initial
surgery to further refine and finish the appearance of the
breast. Any revisions at the donor site, such as dog ear
removal or liposuction, are also performed at this time.
Total number of patients
Complications are infrequent. In a 10-year retrospective review
of 758 DIEP flaps by our unit, 6% of patients returned to the
operating room for flap related problems. Partial flap loss occurred
in 2.5% while total flap loss occurred in less than 1% of all
cases. Problems with the vein or venous anastomosis were almost
eight times more likely than problems with the artery or arterial
anastomosis. Fat necrosis appeared in 13% of flaps. Seroma formation
at the abdominal donor site was approximately 5% and abdominal
hernia occurred in 0.7% of cases.18
Discussion
In our experience, the DIEP flap has shown to be a safe, consistent
and reliable flap for breast reconstruction. The preparation,
marking, harvest and inset described above will be sufficient
to take care of the majority of patients presenting for breast
reconstruction.
On occasion we perform an SIEA flap in a patient instead
of a DIEP flap. This usually occurs when the superficial
inferior epigastric artery and vein are of sufficient size
and calibre to carry the flap, as described above. It is
our experience that usually there is an inverse relationship
between the sizes of the superficial and deep inferior epigastric
systems. The presence of a large superficial artery found
early during the flap dissection can be a warning that no
one or two or even three dominant perforators will be found
in the ipsilateral hemiabdomen of the patient. In a review
of 1095 cases performed in just over the last 8 years since
we have been performing SIEA flaps as described above, 867
(79%) were DIEP flaps and 228 (21%) were SIEA flaps. Complication
rates were similar for both types of flaps, with the absolute
rates of donor site seroma and flap fat necrosis being slightly
higher for the SIEA flaps and an overall flap loss rate
for both flaps approximating 1%. We believe the reasons
to be the course of the SIEA dissection through the groin
lymphatic bed and the typically smaller and more lateral
vascular territory of the superficial system on the abdominal
flap, respectively.19
Sometimes there is a concern that a patient is too thin
or does not have enough tissue in the abdomen for a DIEP
flap. In our experience, the tissue found at the abdominal
donor site is sufficient for reconstruction of mastectomy
defects in most patients. This is true even for most thin
patients. While thin patients have smaller amounts of abdominal
tissue available for reconstruction, they tend to have smaller
breast volumes to replace as well. In a different 8-year
review of 172 patients who had both SIEA and DIEP flaps
for breast reconstruction, the weights of the harvested
flaps averaged approximately 120% of the weights of the
mastectomy specimens in immediate reconstructions.19
Some patients have more fat in the gluteal region than
the abdominal area. In this subset of patients, a gluteal
artery perforator (GAP) flap may be used as a first choice
for breast reconstruction.
If a further amount of additional volume is needed from
the abdomen, a perforator connecting to the deep inferior
epigastric vessels on the side opposite the main pedicle
may be dissected free on the same flap. This permits the
safe use of the entire flap, including the opposite most
lateral portion of the flap (zone 4), which is usually trimmed
and discarded. The flap is folded onto itself and secured
with several deep Vicryl sutures between the layers of Scarpa's
fascia as needed. An additional anastomosis between the
opposite pedicle and a side branch of the main, ipsilateral
flap pedicle is performed first, followed by the standard
anastomosis of the main pedicle. The flap is then inset
with the folded midline portion inferior at the level of
the inframammary fold, and the deep portions deepithelialised
according to standard technique.
The placement of an implant behind a DIEP flap reconstruction
for additional volume is also possible at a later time.
Our experience with the DIEP flap for autogenous breast
augmentation is also increasing. We now find that a lateral
incision at the anterior axillary line provides superior
access both for ease of flap placement and also easy access
to the thoracodorsal vessels as recipients. The entire flap
is deepithelialised and buried during the first stage. The
flap can be monitored safely with implantable continuous
Doppler probes on both the artery and vein.
The question sometimes arises regarding other options for
breast reconstruction in the case of a failed flap. In our
unit over the last 10 years we have found the reliability
of the DIEP and SIEA flaps to be quite high, averaging approximately
98–99%. In the unlikely event of a flap failure,
typically we prefer to use another perforator flap, such
as a GAP flap, for the reconstruction. In all cases the
second perforator flap was successful for the breast reconstruction.
This again keeps the donor site morbidities to a minimum.
In our opinion it is easier and preferable to address the
rare complication of a failed perforator flap breast reconstruction
with minimal donor site morbidity than a successful breast
reconstruction flap with a rare complication such an abdominal
hernia with or without infected mesh.
The DIEP flap is an excellent choice for breast reconstruction,
and is usually the first choice of flap for breast reconstruction
in our practice. Over the past 13 years in our practice it has shown
to be safe and reliable and provide a breast reconstruction with
a superior long-term result with minimal donor site morbidity.
References
1 S.H. Milton, Pedicled
skin flaps: the fallacy of the length: width ratio, Br J Surg
57 (1970), pp. 502–508.
2 S.H. Milton,
Experimental studies on island flaps, Plast Reconstr
Surg 48 (1971), pp. 574–578.
3 I.A. McGregor
and I.T. Jackson, The groin flap, Br J Plast Surg
25 (1972), pp. 3–16.
4 C.R. Hartrampf,
M. Scheflan and P.W. Black, Breast reconstruction with a
transverse abdominal island flap, Plast Reconstr Surg
69 (1982) (2), pp. 216–225.
5 R.K. Daniel and
G.I. Taylor, Distant transfer of an island flap by microvascular
anastomoses, Plast Reconstr Surg 52
(1973), pp. 111–117.
6 G.I. Taylor and
R.K. Daniel, The free flap: composite tissue transfer by
vascular anastomoses, Aust N Z J Surg 43
(1973), pp. 1–3.
7 G.I. Taylor and
R.K. Daniel, The anatomy of several free flap donor site,
Plast Reconstr Surg 56 (1975) (3),
pp. 243–253.
8 G.G. Hallock,
Defatting of flaps by means of suction-assisted lipectomy,
Plast Reconstr Surg 76 (1985), pp.
948–952.
9 L.F. Elliott,
B. Raffel and J. Wade, Segmental latissimus dorsi free flap:
clinical applications, Ann Plast Surg 23
(1989), pp. 231–238.
10 A.M. Feller,
Free TRAM. Results and abdominal wall function, Clin
Plast Surg 21 (1994) (223), p. 232.
11 I. Koshima,
T. Moriguchi, S. Soeda, H. Tanaka and N. Umeda, Free thin
paraumbilical perforator-based flaps, Ann Plast Surg
29 (1992) (1), pp. 12–17.
12 R.J. Allen
and P. Treece, Deep inferior epigastric perforator flap
for breast reconstruction, Ann Plast Surg 32
(1994), p. 32.
13 C.M. Futter,
M.H. Webster, S. Hagen and S.L. Mitchell, A retrospective
comparison of abdominus muscle strength following breast
reconstruction with a free TRAM or DIEP flap, Br J Plast
Surg 53 (2000), p. 578.
14 J. Kaplan
and R. Allen, Cost-based comparison between perforator flaps
and TRAM flaps for breast reconstruction, Plast Reconstr
Surg 105 (2000) (3), pp. 943–948.
15 S. Kroll,
S. Sharma and C. Koutz et al., Postoperative morphine
requirements of free TRAM and DIEP flaps, Plast Reconstr
Surg 107 (2001), p. 338.
16 R. Allen and
A. Heitland, Autogenous augmentation mammaplasty with microsurgical
tissue transfer, Plast Reconstr Surg 112
(2003) (1), pp. 91–100.
17 N. Rogers
and R. Allen, Radiation effects on breast reconstruction
with the deep inferior epigastric perforator flap, Plast
Reconstr Surg 109 (2002) (6), pp. 1919–1924.
18 P. Gill, J.
Hunt and A. Guerra et al., A 10-year retrospective
review of 758 DIEP flaps for breast reconstruction, Plast
Reconstr Surg 113 (2004) (4), pp. 1153–1160.
19 J.W. Granzow,
E.S. Chiu, J.L. Levine, A. Gautam, A. Hellman and W. Rolston
et al., Autologous breast reconstruction using the
superficial inferior epigastric artery flap revisited, Plast
Reconstr Surg 116 (2005) (3) [Supplement:
133].
20 Holstrom H. The free
abdominoplasty flap and its use in breast reconstruction. An experimental
study and clinical case report. Scand J Plast Reconstr Surg. 1979;13(3):423–27.
Journal of Plastic, Reconstructive & Aesthetic Surgery
Volume 59, Issue 6, June 2006, Pages 571-579
|
