• Archives of Plastic Surgery
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• v.45 no.4
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• pp.298-303
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• 2018

Flap thinning is a procedure for making a thick flap thinner. This procedure does more than simply fill in the defected area, and it is better for reconstructing the area both functionally and aesthetically. However, because flap thinning is a rather blind procedure, it may have harmful effects on flap vascularity. Therefore, the vasculature of a flap must be understood before performing flap thinning. This paper analyzes the basic anatomy underlying flap thinning based on the previous anatomic study that categorized flaps into 6 types by their vascular structures. This paper also reviews specific studies of frequently practiced flap procedures (deep inferior epigastric artery perforator flap, thoracodorsal artery perforator flap, and anterolateral thigh flap) and presents important precautions for flap thinning procedures. Finally, this paper briefly examines the axiality of the subdermal plexus, which needs to be taken into account when performing flap thinning.

• Archives of Plastic Surgery
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• v.44 no.2
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• pp.109-116
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• 2017

Background The effect of liposuction on the perforators of the lower abdominal wall has been investigated in several studies. There are controversial results in the literature that have primarily demonstrated the number and patency of the perforators. The aim of this study was to determine the effect of liposuction on the perfusion of perforator-based abdominal flaps using a combined laser-Doppler spectrophotometer (O2C, Oxygen to See, LEA Medizintechnik). Methods Nine female patients undergoing classical abdominoplasty were included in the study. Perforators and the perfusion zones of the deep inferior epigastric artery flap were marked on the patient's abdominal wall. Flap perfusion was quantitatively assessed by measuring blood flow, velocity, capillary oxygen saturation, and relative amount of hemoglobin for each zone preoperatively, after tumescent solution infiltration, following elevation of the flap on a single perforator, and after deep and superficial liposuction, respectively. Results The measurements taken after elevation of the flap were not significantly different than measurements taken after the liposuction procedures. Conclusions The liposuction procedure does not significantly alter the perfusion of perforator-based abdominal flaps in the early period. The abdominal tissue discarded in a classic abdominoplasty operation can be raised as a perforator flap and has been demonstrated to be a unique model for clinical research.

• Archives of Plastic Surgery
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• v.50 no.2
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• pp.153-155
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• 2023

The vascular anatomy of the deep inferior epigastric artery perforator (DIEP) flap has been well studied in the planning for autologous breast reconstruction. Preoperative imaging with computed tomography angiography (CTA) provides accurate assessment of this vascular anatomy, which varies widely across patients. Several papers to date have described their encounter with an anomalous "epiperitoneal" or "peritoneo-cutaneous" perforator during flap harvest, a perforator that pierces the posterior rectus sheath from a peritoneal origin, to traverse rectus abdominis and supply the DIEP flap integument. In the course of over 3,000 CTA assessments of the vascular anatomy of the abdominal wall, we have encountered dominant peritoneo-cutaneous perforators in 1% of cases, and smaller perforators seen in many more cases, approaching 5% of cases. With increasing sensitivity of imaging, we also describe a unique case of multiple large bilateral peritoneo-cutaneous perforators, and present these findings in the context of DIEP flap harvest. It is critical to recognize these peritoneo-cutaneous perforators preoperatively to avoid mistaking them for a DIEP during the raising of a DIEP flap. The routine use of preoperative CTA enables the safe identification of individual vascular anatomy, including significant peritoneo-cutaneous perforators.

• Archives of Plastic Surgery
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• v.50 no.4
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• pp.354-360
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• 2023

Background The Island transverse rectus abdominis musculocutaneous (TRAM) flap is well vascularized with very reliable blood flow, because all perforators of the zone I are included when it is harvested. The number of perforators, topographic mapping, and their relationship with reconstructed outcomes were investigated. Methods Fifty patients with Island TRAM breast reconstruction from September 2021 to August 2022 were investigated. The zone I was divided into a total of eight sections. Under the loupe magnification, all perforators larger than 0.5 mm in zone I were counted with fine dissection, and photographs were taken in background of vessel loops. Complications like flap necrosis, seroma, and hematoma were also investigated. Result There are 12 ideal perforators on average in zone I such as one perforator in section I, II, IV, V, VI, VIII, and three perforators in section III and VII. However, two perforators (M6 and L6) below arcuate line were sacrificed in the time of flap harvest to prevent hernia. Island TRAM included 10 perforators on average (5 perforators in each side) above arcuate line to be transferred to the recipient site. Only minor complications were identified. Conclusion The Island TRAM flap includes 10 perforators to get the vigorous blood flow. The periumbilical to upper medial perforators become more dominant in the perfusion of the flap after deep inferior epigastric artery division. Well preserved perforators will guarantee the satisfactory breast reconstruction with the least complication.

• Journal of Yeungnam Medical Science
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• v.23 no.1
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• pp.1-9
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• 2006

Breast reconstruction provides dramatic improvement for patients with severe deformity. The reconstruction not only restores aesthetically acceptable breast for patients with mastectomy deformity but also recovers psychological trauma of 'losing feminity' after the cancer mastectomy. There are many options for breast reconstruction from simple prosthetic insertion to a flap operation using autologous abdominal tissue. The choice of operation method depends on the physical condition of the patient, smoking habits, and economic status. Among the many options, the method that uses the lower abdominal tissue is known as the TRAM (transverse rectus abdonimis myocutaneous) flap. Since the introduction of the TRAM flap in 1982 by Hartrampf, the art of breast reconstruction using lower abdominal tissue has been progressively refined to pedicle flap, muscle-sparinga TRAM flap, and recently there have been exciting and revolutionary changes associated with the adoption of the concept of perforator flap. This refined method of breast reconstruction utilizes lower abdominal tissue nourished by the deep inferior epigastric perforator (DIEP). With the DIEP free flap, almost all of the rectus muscle and anterior rectus sheath are preserved and the donor morbidity is minimized. Different from previous flap methods using lower abdominal tissue, DIEP free flap method preserves function of the rectus muscle completely. 1) Understanding the entire progression of breast reconstruction methods using lower abdominal tissue is necessary for plastic surgeons; the understanding of each step of the exciting progression and the review of the past history of the TRAM flap may provide insight for future development.

• Archives of Plastic Surgery
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• v.39 no.1
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• pp.3-10
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• 2012

The free muscle-sparing transverse rectus abdominis myocutaneous (MS-TRAM) and deep inferior epigastric perforator (DIEP) flaps involve transferring skin and subcutaneous tissue from the lower abdominal area and have many features that make them well suited for breast reconstruction. The robust blood supply of the free flap reduces the risk of fat necrosis and also enables aggressive shaping of the flap for breast reconstruction to optimize the aesthetic outcome. In addition, the free MS-TRAM flap and DIEP flap require minimal donor-site sacrifice in most cases. With proper patient selection and safe surgical technique, the free MS-TRAM flap and DIEP flap can transfer the lower abdominal skin and subcutaneous tissue to provide an aesthetically pleasing breast reconstruction with minimal donor-site morbidity.

• Archives of Reconstructive Microsurgery
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• v.22 no.1
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• pp.7-12
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• 2013

Purpose: Breast reconstruction with lower abdominal tissue can produce the best outcome with acceptable rates of long-term complication. However, for cases in which sufficient abdominal tissue is not available, an superior gluteal artery perforator (SGAP) flap can be considered as the next option for autologous breast reconstruction. Materials and Methods: Among a total of 63 women who underwent breast reconstruction with free autologous tissue transfer from July 2010 to April 2011, SGAP flap was performed for four patients. In two cases, patients did not have enough abdominal tissue for sizable breast reconstruction. In another case, the patient had a long abdominal scar due to donor hepatectomy of liver transplantation. In the last case, which was a revisional case after radiation necrosis of a previous pedicled transverse rectus abdominis musculocutaneous (TRAM) flap, a large amount of healthy skin and soft tissue was needed. SGAP flap was elevated in lateral decubitus position. The internal mammary vessels were used for recipient vessels in all cases. Results: Breast reconstruction was performed successfully in all four cases without flap loss. Donor site complication was not observed, except for one case of seroma. The shape of the reconstructed breast was satisfactory in all patients. Conclusion: SGAP flap is an excellent alternative option for the TRAM or deep inferior epigastric artery perforator flap for breast reconstruction. In terms of narrower width, harder consistency of soft tissue, and shorter pedicle, it is clear that the SGAP flap is less competent than the TRAM flap. However, in cases where abdominal tissue is not available, SGAP flap is the only way of providing a large amount of healthy tissue.

• Archives of Hand and Microsurgery
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• v.23 no.4
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• pp.281-289
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• 2018

Purpose: Preoperative surgical planning utilizing computed tomography angiography (CTA) has now become a routine in many practices. We analyzed the course of the deep inferior epigastric artery (DIEA) and its perforators (DIEP) that would either facilitate or hinder flap dissection based on CTA to aid surgical planning. Methods: The 115 consecutive patients who underwent abdominally based free flap breast reconstruction were enrolled in this prospective study. DIEA/P courses were categorized mainly according to their intramuscular courses and their incidences were investigated. Results: A total of 425 perforators were identified preoperatively on the CTA, with an average number of 3.7 distinctly visualized in the entire flap territory. Eighty-nine perforators (20.9%) had a favorable (less than 1 cm intramuscular course) pattern, namely long submuscular (34.8% of the patients), long subfascial (15.6%), and total circummuscular (13.9%). Overall 56.5% of the patients had at least one favorable DIEA/P. On the other hand, absence of DIEA and absence of adequate (>1 mm) DIEP was reported in 3 and 8 hemiabdomen. Conclusion: Preoperative CTA evaluation of DIEA/P can be used to identify favorable as well as unfavorable courses for dissection to aid surgical planning.

• Archives of Plastic Surgery
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• v.49 no.3
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• pp.324-331
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• 2022

Prior abdominal liposuction can be viewed as a relative or absolute contraindication to abdominally based autologous breast reconstruction given concerns for damaged perforators and scarring complicating intraoperative dissection. This systematic review aims to explore the outcomes of abdominally based breast reconstruction in patients with a history of abdominal liposuction. A Preferred Reporting Items for Systematic Reviews and Meta-Analyses-guided literature search was conducted using PubMed, Scopus, and Web of Science from the earliest available date through June 2020. Deep inferior epigastric perforator, muscle-sparing transverse rectus abdominis musculocutaneous (TRAM), superficial inferior epigastric artery, and pedicled TRAM flaps were included for evaluation. Complications included total or partial flap loss, fat necrosis, seroma, delayed wound healing, and donor site complications. After inclusion criteria were applied, 336 non-duplicate articles were screened, yielding 11 for final review, representing 55 flaps in 43 patients. There was no instance of total flap loss, eight (14.5%) flaps developed partial loss or fat necrosis, three (5.4%) flaps had delayed wound healing, and two (4.6%) patients had donor site complications. Most authors (8/11) utilized some type of preoperative imaging. Doppler ultrasonography was the most used modality, and these patients had the lowest rate of partial flap loss or flap fat necrosis (8%), followed by those without any preoperative imaging (10%). In conclusion, this review supports that patients undergoing abdominally based autologous breast reconstruction with a history of abdominal liposuction are not at an increased risk of flap or donor site complications. Although preoperative imaging was common, it did not reliably decrease complications. Further prospective studies are needed to address the role of imaging in improving outcomes.

• Archives of Plastic Surgery
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• v.46 no.6
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• pp.599-602
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• 2019

We report a case of autologous breast reconstruction in which a thoracodorsal vessel was used as a recipient vessel after a hypoplastic internal mammary vessel was found on preoperative computed tomography (CT) angiography. A 46-year-old woman with no underlying disease was scheduled to undergo skin-sparing mastectomy and breast reconstruction using a deep inferior epigastric artery perforator flap. Preoperative CT angiography showed segmental occlusion of the right subclavian artery with severe atherosclerosis and calcification near the origin of the internal mammary artery, with distal flow maintained by collateral branches. The thoracodorsal artery was selected to be the recipient vessel because CT showed that it was of adequate size and was not affected by atherosclerosis. The patient experienced no postoperative complications, and the flap survived with no vascular complications. The breasts were symmetrical at a 6-month follow-up. This case highlights that preoperative vascular imaging modalities may help surgeons avoid using diseased vessels as recipient vessels in free flap breast reconstructions.