Journal of Plastic, Reconstructive & Aesthetic Surgery (2014) 67, 219e225
Harvesting free abdominal perforator flaps in the presence of previous upper abdominal scars Moustapha Hamdi*, Mikko Larsen, Barbara Craggs, Bert Vanmierlo, Assaf Zeltzer Department of Plastic and Reconstructive Surgery, Brussels University Hospital, Vrij Universiteit Brussel (VUB), Brussels, Belgium Received 14 May 2013; accepted 28 October 2013
KEYWORDS Scar; Subcostal Scar; Chevron; DIEP flap; SIEA flap; Breast reconstruction; Donor site; Complication
Summary Purpose: Subcostal scars pose a risk of upper abdominal flap ischaemia when raising a free abdominal flap. The aim of this study was to describe a clinical approach to increase flap reliability and donor site healing in the presence of transverse abdominal scars while harvesting lower abdominal free flaps. Methods: A total of 11 patients who had subcostal scars and one who had an extended subcostal scar (rooftop or chevron incision) underwent free abdominal flaps for breast reconstruction. Preoperative radiological imaging was used to evaluate the blood supply to the planned flaps. A classification of clinical approaches (IeIV) was used. When the cranial (the abdominal closure) flap width was equal to or greater than half length, a caudal (the breast) flap could safely be harvested (Type I); if not, the cranial flap was enlarged by more caudal flap planning (Type II), an oblique design of the free flap (Type III) or by lowering the free flap marking more distally (Type IV) with a sparing of the peri-umbilical perforators to preserve blood supply to the caudal (abdominal closure) flap. Results: Unilateral free deep inferior epigastric perforator (DIEP) and superficial inferior epigastric artery (SIEA) flaps were successfully harvested in eight and two cases, respectively. In two cases, a bipedicled DIEP/SIEA flap was harvested for unilateral breast reconstruction. Slight abdominal wound slough occurred in one patient; however, no ischaemia resulted in flaps or at donor sites.
* Corresponding author. Department of Plastic and Reconstructive Surgery, Brussels University Hospital (UZBrussel), Laarbeeklaan 101, 1090 Brussels, Belgium. Tel.: þ32 2 477 62 50; fax: þ32 2 477 62 51. E-mail address: [email protected] (M. Hamdi). 1748-6815/$ - see front matter ª 2013 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.bjps.2013.10.047
220
M. Hamdi et al. Conclusions: Using a pragmatic approach to flap design, based on clinical classification, we have found that both flap and donor site morbidity can be avoided in patients who have previous upper abdominal scars. Level of evidence: IV, Therapeutic. ª 2013 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
The deep inferior epigastric perforator (DIEP) flap is the gold standard in microsurgical breast reconstruction and the first choice of the donor site at our institution. The large amount of available tissue enabling shaping of the reconstruction to natural-appearing breasts, the reliable vascular anatomy and an aesthetically pleasing donor site scar encourage its use. However, in some patients the DIEP flap is not considered the optimal choice, as previous abdominal surgeries with resulting scars may threaten the vascularity within the flap.1e3 Previous cholecystectomy, for instance, may lead to skin and fat necrosis or wound breakdown at the donor site or in the flap area distal to the scar.4,5 The problem of previous abdominal scars endangering the DIEP flap harvest is not addressed very often.6 This may be due to the availability of several alternatives such as the transverse myocutaneous gracilis (TMG) flap, the free gluteal perforator flap or the myocutaneous latissimus dorsi flap that enable most surgeons to avoid risks for the flap or the donor site. However, the abdomen may still be a donor site for flaps despite the presence of scars. Modifications to flap planning or using different strategies in harvesting the flap could offer a possible and safe donor site closure. When the lower
abdominal pannus is redundant, the flap can be planned more caudally or obliquely to allow more width between the old upper scar and cranial incision of the harvested free flap. Sometimes, however, the lower abdominal tissue is limited because of a lack of skin-fat excess or the presence of a midline infraumbilical scar. Several reports have presented solutions to overcome this problem.7e14 The purpose of this article was to present a combination of approaches to allow safe DIEP flap harvest in the presence of previous subcostal and/or upper abdominal scars.
Material & methods A retrospective case note review was performed in a series of 866 patients who underwent breast reconstruction with free abdominal perforator (DIEP and superficial inferior epigastric artery (SIEA)) flaps by the senior author from 2001 to 2011. Among them, 12 (1.04%) patients underwent free abdominal flaps for breast reconstruction despite the presence of transverse scars in the upper abdomen. Of the patients, 11 had subcostal scars and one patient had an extended (full transverse) subcostal scar (rooftop or chevron incision). Preoperative imaging (colour Doppler or computed
Figure 1 A Classification of our clinical approach of free lower abdominal flap harvesting with the presence of subcostal/upper abdominal scars. I: standard flap design (abdominal closure flap between subcostal scar and upper incision line has width halve’ length) II: the flap is skewed away from subcostal scar and harvested based on SIE vessels or low located perforators. III: the flap is designed obliquely to increase abdominal closure flap width. IV: in case of Chevron scar: the flap is skewed more distally to keep peri-umbilical perforators to the abdominal closure flap. Flap can be harvested on a combination of bipedicled abdominal flaps to increase the amount of harvested tissue.
Harvesting free abdominal perforator flaps
221
Figure 2 A case of 52-year old patient who underwent a DIEP flap primary breast reconstruction. The DIEP flap was safely harvested despite the presence of previous subcostal and right nephrectomy scars. (a). A preoperative view shows the flap design. (b). A postoperative view shows a successful flap transfer without donor site complication.
tomography (CT) angiogram) was used to evaluate the blood supply (DIEPs and SIEA) to the planned flaps.15
Surgical technique Preoperatively, the DIEP flap is outlined on the patient’s lower abdomen including the position of the perforators as
found on preoperative imaging (colour Doppler or CT angiogram). Tailored approaches may be employed according to the specific situation (Figure 1). We developed a clinical classification depending on the sum of three elements: skin distance between the subcostal scar and the upper incision line of the flap, available vascular pedicle(s) and perforator locations and the required flap tissue for
Figure 3 A 48-year old patient in whom the DIEP flap was designed obliquely to allow larger skin flap between the existing subcostal scar and the upper skin incision of the DIEP flap. (a). The DIEP flap was skewed obliquely away from the subcostal scar. (b). The flap was harvested successfully without abdominal flap necrosis. The abdominal scar was revised 3 months after flap harvesting.
222
M. Hamdi et al.
Figure 4 A 45-year patient who had a Chevron scar underwent a bi-pedicled DIEP/SIEA flap for right breast reconstruction. The flap was designed more distally in order to keep the peri-umbilical perforators to insure adequate blood supply to the skin flap between the chevron scar and the upper edge of the planned free flap. (a). A preoperative view. (b). The flap was designed away (red line) from the chevron scar. (c). The bi-pedicled free flap was based on a perforator at the right side (double-arrow) and on the SIEA vessels. Meanwhile both peri-umbilical perforators (single arrows) were kept within the skin bridge between the chevron scar and the upper incision of the free flap. (d). The donor site after harvesting the free flap. Both peri-umbilical perforators were dissected into the deep epigastric pedicles in both sides. (e). The bi-pedicled DIEAP (double-arrow)/SIEA (single arrow) flap. (f).
Harvesting free abdominal perforator flaps Table 1
223
shows patients characteristics with the used clinical approach in flap design and harvesting.
Patient
Age
Scars
Flap design
Classification
Flap type
Abdominal Complications
1 2
48 52
Oblique Standard
III I
DIEP DIEP
Non Non
3 4
64 54
Standard Standard
I I
DIEP DIEP
Non Non
5 6 7 8 9
58 52 61 45 55
Distal Oblique Distal More distal Standard
II III II IV I
SIEA DIEP DIEP DIEP/SIEA DIEP
Non Non Non Non Wound dehiscence
10 11 12
52 47 51
Subcostal Subcostal Nephrectomy Subcostal Subcostal C-section Subcostal Subcostal Subcostal Chevron Subcostal C-section Subcostal Subcostal Subcostal
Distal Oblique Distal
II III II
SIEA DIEP DIEP/SIEA
Non Non Non
breast reconstruction. Using this classification, four clinical approaches could be used to insure flap harvesting without abdominal skin risk of necrosis despite the presence of the subcostal scar: Type I: When there is a large distance (abdominal closure flap) between the subcostal scar and the cranial incision line of the free flap (width half length), the free flap can be designed in the standard way (Figure 2). If the distance is shorter than this, one of the following types could be used. Type II: When adequate SIE vessels (SIEA diameter 1 mm) are available, the flap is harvested as an SIEA flap or as a DIEP flap but based on low-localised perforators; flap can then be designed more caudal to allow a larger skin bridge. Type III: The flap can be designed using an oblique orientation of the free flap design, which increases the width of the abdominal closure flap (Figure 3). Type IV: When the upper abdominal flap is much smaller or when a chevron scar is present, the flap is skewed as far away from the subcostal scar with the preservation of peri-umbilical perforators to the abdominal closure flap (Figure 4). In the last situation, the skin area caudal to the subcostal scar is left attached to the perforators (Figure 4(b)e(d)). After harvesting the DIEP flap and closing the anterior rectus sheath, the abdominal closure flap is prepared for direct closure of the donor site. Care is taken during undermining to identify a perforating vessel supplying the subcutaneous tissue and skin on the side opposite to the pedicle of the DIEP flap (Figure 4(c)). It is irrelevant whether or not the perforator is on the same side as the
scar, but it is advisable that the perforator is not on the same side as the sacrificed inferior epigastric vessels. The perforator is then dissected to allow abdominal donor site closure without tension on the perforator vessel (Figure 4(d)). The incised fascia is closed directly paying attention to not strangulate the newly positioned perforator. Perforator flap harvesting then proceeds with preservation of the superficial epigastric vein for the option of venous supercharging. The flap is then transferred to the thorax and a conventional end-to-end anastomosis between the inferior epigastric vessels and the internal mammary vessels is performed. Finally, after confirmation of adequate flap perfusion, the flap is inset with appropriate shaping performed. A DIEP or SIEA flap territory includes zone I, II and a variable extension over zone III.16 When a larger flap is required (all three zones or/and zone 4), a contralateral pedicle (either DIE or SIE) is also dissected and a crossover anastomosis is performed between the left and right side of the flap using the continuation of the epigastric vessels and/or a side branch of either epigastric perforator (Figure 4(f)).12
Results Twelve patients, who underwent free abdominal perforator flaps, had previous upper abdominal scars. The time interval between the previous abdominal surgery and free flap breast reconstruction was 6 years on average (range 3e18 years). The patient characteristics are summarised in Table 1. DIEP and SIEA flaps were done in eight and two patients, respectively. A bipedicled flap was used in two patients due to a lack of sufficient lower abdominal pannus.
The SIE vessels were anastomosed to the cranial stump of the DIE vessels (single arrow) and the main DIE pedicle was then anastomosed to the internal mammary vessels (double-arrow). (g). The median part of the chevron scar was release to provide easier closure of the donor site. (h). The outcome at one year postoperatively. The patient had a contralateral mastopexy 3 month later. (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article).
224 One patient had previous liposuction and the other patient had a low body mass index (BMI). In this last patient (Figure 4(d)), two caudal (to subcostal scar) perforators were preserved into the abdominal closure flap after harvesting the DIEP/SIEA flap. One perforator was dissected on each side to allow enough length for flap mobilisation and abdominal closure. Flap design was done as standard or distal planned (types I and II) in four (33.3%) patients each. Types III and IV were performed in only three (25%) and in one case (8.4%), respectively. All flaps survived without complications. Hospital stay was 6 days on average (range 4e7 days). A slight abdominal wound slough occurred in one patient; however, no ischaemia resulted in any of these patients. With a mean follow-up of 5 years and 3 months, there were no further donor site complications.
Discussion Most abdominal scars do not preclude the use of the DIEP flap but may dictate how much tissue is available for use.2,6,8e14 Whereas an appendectomy or a Pfannenstiel scar is usually of no consideration, and may even serve as a ‘delay’,1 a vertical infraumbilical, cholecystectomy or chevron scar may pose a threat to the flap and/or donor site, due to permanent closure of choke vessels.2,8e14 Losken et al. retrospectively reviewed their experience with transverse rectus abdominis myocutaneous (TRAM) flap breast reconstruction in patients with subcostal scars and found an up to 6.5-fold increased risk for skin necrosis on the abdomen compared to patients without previous incisions.5 There were no significant differences in breastrelated complications. Donor site complications were higher with abdominal wall skin necrosis being significantly higher in patients with a subcostal incision (25%) compared with those patients without abdominal wall scars (5%).5 In the literature, other possible solutions to overcome this problem include higher positioning of the abdominal scar or asymmetric skewing of the flap outline. Both techniques may result in a suboptimal abdominal scar position or asymmetry. Takeishi et al. found, in a similar investigation, an eightfold increased complication rate and suggested some flap modification that places the donor scar much higher in the abdomen to avoid such problems.4 In a reply to this article, Weiss17 introduced an asymmetric flap outline to escape the predictable troubles of skin damage at the cephalic wound edge. Our results showed that most of the patients with subcostal scars could still undergo free abdominal flaps for breast reconstruction. Modification to flap design by skewing the flap more distally or obliquely away from the subcostal scar allows safe flap harvesting without abdominal closure flap complications in 91% of the cases. However, preoperative vascular studies using CT scan or Doppler imaging are mandatory to plan the free abdominal flaps. The problem of donor site necrosis in the presence of transverse abdominal scars may be overcome by allowing the abdominal flap to remain pedicled.9 Extensive cranial undermining for donor site closure may compromise its survival. Including the scar within the harvested flap, which can be dissected as a high-designed deep inferior epigastric artery perforator (DIEAP) flap or a pedicled TRAM if the
M. Hamdi et al. contralateral superior epigastric vessels are left intact, could only be done when there are still perforators to the skin and will result in a mid-abdomen horizontal scar. Inspired by perforator flap techniques, we describe a new way to manage this problem. This technique can also be applied in simple abdominoplasty when disturbed microcirculation is anticipated due to subcostal scars in the cephalic portion of the abdominal flap that has to be undermined for wound closure. Preserving one or more of the peri-umbilical perforators may reduce the amount of the harvested flap because the upper part of the DIEP flap will be included in the abdominal closure flap. In this situation, the harvested flap can include the four zones of the lower abdomen. However, a standard flap is perfused by one pedicle but it is not able to vascularise all four zones. To overcome these problems, several techniques can be employed based on experience with midline scars.8,10e14 To increase flap resilience, we described using two pedicles that are interconnected on a side table and combining the SIEA on one side to the DIEP from the other side.12 The interpedicle anastomosis may be performed in any of four patterns.12 In summary, abdominal scars from previous surgeries may influence the harvesting of a perforator flap. Our clinical approach is to try to maximise the perfusion to the upper abdominal flap by either widening/lengthening and or ‘augmenting’ the supply of the upper flap (with perforator preservation). A bipedicled free flap is also an option to provide an adequate amount of tissue when the anatomical condition does not allow harvesting ample tissue using a standard flap.
Authors’ contribution M.H. conceived and designed the new concept and supervised the preparation of the manuscript. M.L. helped in writing the original manuscript. A.Z., B.C. and B.V. provided technical and editing support. All authors discussed the results and implications and commented on the manuscript at all stages.
Conflict of interest None.
Funding None.
References 1. Mahajan AL, Zeltzer A, Claes KE, Van Landuyt K, Hamdi M. Are pfannenstiel scars a boon or a curse for DIEP flap breast reconstructions? Plast Reconstr Surg 2012 Apr;129(4):797e805. 2. Hsieh F, Kumiponjera D, Malata CM. An algorithmic approach to abdominal flap breast reconstruction in patients with preexisting scarseresults from a single surgeon’s experience. J Plast Reconstr Aesthet Surg 2009 Dec;62(12):1650e60. 3. De Frene B, Van Landuyt K, Hamdi M, et al. Free DIEAP and SGAP flap breast reconstruction after abdominal/gluteal liposuction. J Plast Reconstr Aesthet Surg 2006;59(10):1031e6.
Harvesting free abdominal perforator flaps 4. Takeishi M, Shaw WW, Ahn CY, Borud LJ. TRAM flaps in patients with abdominal scars. Plast Reconstr Surg 1997 Mar;99(3): 713e22. 5. Losken A, Carlson GW, Jones GE, Culbertson JH, Schoemann M, Bostwick 3rd J. Importance of right subcostal incisions in patients undergoing TRAM flap breast reconstruction. Ann Plast Surg 2002 Aug;49(2):115e9. 6. Rozen WM, Garcia-Tutor E, Alonso-Burgos A, Corlett RJ, Taylor GI, Ashton MW. The effect of anterior abdominal wall scars on the vascular anatomy of the abdominal wall: a cadaveric and clinical study with clinical implications. Clin Anat 2009 Oct;22(7):815e22. 7. Pennington DG, Nettle WJ, Lam P. Microvascular augmentation of the blood supply of the contralateral side of the free transverse rectus abdominis musculocutaneous flap. Ann Plast Surg 1993 Aug;31(2):123e6. 8. Ali RS, Garrido A, Ramakrishnan V. Stacked free hemi-DIEP flaps: a method of autologous breast reconstruction in a patient with midline abdominal scarring. Br J Plast Surg 2002 Jun; 55(4):351e3. 9. Schoeller T, Huemer GM, Kolehmainen M, Otto-Schoeller A, Wechselberger G. Management of subcostal scars during DIEPflap raising. Br J Plast Surg 2004 Sep;57(6):511e4. 10. Das-Gupta R, Busic V, Begic A. Deep inferior epigastric perforator flap (DIEP) breast reconstruction in the presence of a midline vertical scar. J Plast Reconstr Aesthet Surg 2006;59(6): 675e6.
225 11. Schoeller T, Wechselberger G, Roger J, Hussl H, Huemer GM. Management of infraumbilical vertical scars in DIEP-flaps by crossover anastomosis. J Plast Reconstr Aesthet Surg 2007;60: 524e8. 12. Hamdi M, Khuthaila DK, Van Landuyt K, Roche N, Monstrey S. Double-pedicle abdominal perforator free flaps for unilateral breast reconstruction: new horizons in microsurgical tissue transfer to the breast. J Plast Reconstr Aesthet Surg 2007; 60(8):904e12. 13. Beahm EK, Walton RL. The efficacy of bilateral lower abdominal free flaps for unilateral breast reconstruction. Plast Reconstr Surg 2007 Jul;120(1):41e54. 14. Rabey NG, Erel E, Malata CM. Double-pedicled abdominal free flap using an entirely new microvascular combination of DIEP and SIEA vascular pedicles for unilateral breast reconstruction: a novel addition to the Hamdi classification. Plast Reconstr Surg 2012 Nov;130(5):767ee9e. 15. Hamdi M, Van Landuyt K, Van Hedent E, Duyck P. Advances in autogenous breast reconstruction: the role of preoperative perforator mapping. Ann Plast Surg 2007 Jan;58(1):18e26. 16. Holm C, Mayr M, Ho ¨fter E, Ninkovic M. Perfusion zones of the DIEP flap revisited: a clinical study. Plast Reconstr Surg 2006 Jan;117(1):37e43. 17. Weiss PR. TRAM flap breast reconstruction in patients with previous abdominal scars. Plast Reconstr Surg 1999 Mar; 103(3):1100e1.
Harvesting free abdominal perforator flaps in the presence of previous upper abdominal scars Moustapha Hamdi*, Mikko Larsen, Barbara Craggs, Bert Vanmierlo, Assaf Zeltzer Department of Plastic and Reconstructive Surgery, Brussels University Hospital, Vrij Universiteit Brussel (VUB), Brussels, Belgium Received 14 May 2013; accepted 28 October 2013
KEYWORDS Scar; Subcostal Scar; Chevron; DIEP flap; SIEA flap; Breast reconstruction; Donor site; Complication
Summary Purpose: Subcostal scars pose a risk of upper abdominal flap ischaemia when raising a free abdominal flap. The aim of this study was to describe a clinical approach to increase flap reliability and donor site healing in the presence of transverse abdominal scars while harvesting lower abdominal free flaps. Methods: A total of 11 patients who had subcostal scars and one who had an extended subcostal scar (rooftop or chevron incision) underwent free abdominal flaps for breast reconstruction. Preoperative radiological imaging was used to evaluate the blood supply to the planned flaps. A classification of clinical approaches (IeIV) was used. When the cranial (the abdominal closure) flap width was equal to or greater than half length, a caudal (the breast) flap could safely be harvested (Type I); if not, the cranial flap was enlarged by more caudal flap planning (Type II), an oblique design of the free flap (Type III) or by lowering the free flap marking more distally (Type IV) with a sparing of the peri-umbilical perforators to preserve blood supply to the caudal (abdominal closure) flap. Results: Unilateral free deep inferior epigastric perforator (DIEP) and superficial inferior epigastric artery (SIEA) flaps were successfully harvested in eight and two cases, respectively. In two cases, a bipedicled DIEP/SIEA flap was harvested for unilateral breast reconstruction. Slight abdominal wound slough occurred in one patient; however, no ischaemia resulted in flaps or at donor sites.
* Corresponding author. Department of Plastic and Reconstructive Surgery, Brussels University Hospital (UZBrussel), Laarbeeklaan 101, 1090 Brussels, Belgium. Tel.: þ32 2 477 62 50; fax: þ32 2 477 62 51. E-mail address: [email protected] (M. Hamdi). 1748-6815/$ - see front matter ª 2013 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.bjps.2013.10.047
220
M. Hamdi et al. Conclusions: Using a pragmatic approach to flap design, based on clinical classification, we have found that both flap and donor site morbidity can be avoided in patients who have previous upper abdominal scars. Level of evidence: IV, Therapeutic. ª 2013 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
The deep inferior epigastric perforator (DIEP) flap is the gold standard in microsurgical breast reconstruction and the first choice of the donor site at our institution. The large amount of available tissue enabling shaping of the reconstruction to natural-appearing breasts, the reliable vascular anatomy and an aesthetically pleasing donor site scar encourage its use. However, in some patients the DIEP flap is not considered the optimal choice, as previous abdominal surgeries with resulting scars may threaten the vascularity within the flap.1e3 Previous cholecystectomy, for instance, may lead to skin and fat necrosis or wound breakdown at the donor site or in the flap area distal to the scar.4,5 The problem of previous abdominal scars endangering the DIEP flap harvest is not addressed very often.6 This may be due to the availability of several alternatives such as the transverse myocutaneous gracilis (TMG) flap, the free gluteal perforator flap or the myocutaneous latissimus dorsi flap that enable most surgeons to avoid risks for the flap or the donor site. However, the abdomen may still be a donor site for flaps despite the presence of scars. Modifications to flap planning or using different strategies in harvesting the flap could offer a possible and safe donor site closure. When the lower
abdominal pannus is redundant, the flap can be planned more caudally or obliquely to allow more width between the old upper scar and cranial incision of the harvested free flap. Sometimes, however, the lower abdominal tissue is limited because of a lack of skin-fat excess or the presence of a midline infraumbilical scar. Several reports have presented solutions to overcome this problem.7e14 The purpose of this article was to present a combination of approaches to allow safe DIEP flap harvest in the presence of previous subcostal and/or upper abdominal scars.
Material & methods A retrospective case note review was performed in a series of 866 patients who underwent breast reconstruction with free abdominal perforator (DIEP and superficial inferior epigastric artery (SIEA)) flaps by the senior author from 2001 to 2011. Among them, 12 (1.04%) patients underwent free abdominal flaps for breast reconstruction despite the presence of transverse scars in the upper abdomen. Of the patients, 11 had subcostal scars and one patient had an extended (full transverse) subcostal scar (rooftop or chevron incision). Preoperative imaging (colour Doppler or computed
Figure 1 A Classification of our clinical approach of free lower abdominal flap harvesting with the presence of subcostal/upper abdominal scars. I: standard flap design (abdominal closure flap between subcostal scar and upper incision line has width halve’ length) II: the flap is skewed away from subcostal scar and harvested based on SIE vessels or low located perforators. III: the flap is designed obliquely to increase abdominal closure flap width. IV: in case of Chevron scar: the flap is skewed more distally to keep peri-umbilical perforators to the abdominal closure flap. Flap can be harvested on a combination of bipedicled abdominal flaps to increase the amount of harvested tissue.
Harvesting free abdominal perforator flaps
221
Figure 2 A case of 52-year old patient who underwent a DIEP flap primary breast reconstruction. The DIEP flap was safely harvested despite the presence of previous subcostal and right nephrectomy scars. (a). A preoperative view shows the flap design. (b). A postoperative view shows a successful flap transfer without donor site complication.
tomography (CT) angiogram) was used to evaluate the blood supply (DIEPs and SIEA) to the planned flaps.15
Surgical technique Preoperatively, the DIEP flap is outlined on the patient’s lower abdomen including the position of the perforators as
found on preoperative imaging (colour Doppler or CT angiogram). Tailored approaches may be employed according to the specific situation (Figure 1). We developed a clinical classification depending on the sum of three elements: skin distance between the subcostal scar and the upper incision line of the flap, available vascular pedicle(s) and perforator locations and the required flap tissue for
Figure 3 A 48-year old patient in whom the DIEP flap was designed obliquely to allow larger skin flap between the existing subcostal scar and the upper skin incision of the DIEP flap. (a). The DIEP flap was skewed obliquely away from the subcostal scar. (b). The flap was harvested successfully without abdominal flap necrosis. The abdominal scar was revised 3 months after flap harvesting.
222
M. Hamdi et al.
Figure 4 A 45-year patient who had a Chevron scar underwent a bi-pedicled DIEP/SIEA flap for right breast reconstruction. The flap was designed more distally in order to keep the peri-umbilical perforators to insure adequate blood supply to the skin flap between the chevron scar and the upper edge of the planned free flap. (a). A preoperative view. (b). The flap was designed away (red line) from the chevron scar. (c). The bi-pedicled free flap was based on a perforator at the right side (double-arrow) and on the SIEA vessels. Meanwhile both peri-umbilical perforators (single arrows) were kept within the skin bridge between the chevron scar and the upper incision of the free flap. (d). The donor site after harvesting the free flap. Both peri-umbilical perforators were dissected into the deep epigastric pedicles in both sides. (e). The bi-pedicled DIEAP (double-arrow)/SIEA (single arrow) flap. (f).
Harvesting free abdominal perforator flaps Table 1
223
shows patients characteristics with the used clinical approach in flap design and harvesting.
Patient
Age
Scars
Flap design
Classification
Flap type
Abdominal Complications
1 2
48 52
Oblique Standard
III I
DIEP DIEP
Non Non
3 4
64 54
Standard Standard
I I
DIEP DIEP
Non Non
5 6 7 8 9
58 52 61 45 55
Distal Oblique Distal More distal Standard
II III II IV I
SIEA DIEP DIEP DIEP/SIEA DIEP
Non Non Non Non Wound dehiscence
10 11 12
52 47 51
Subcostal Subcostal Nephrectomy Subcostal Subcostal C-section Subcostal Subcostal Subcostal Chevron Subcostal C-section Subcostal Subcostal Subcostal
Distal Oblique Distal
II III II
SIEA DIEP DIEP/SIEA
Non Non Non
breast reconstruction. Using this classification, four clinical approaches could be used to insure flap harvesting without abdominal skin risk of necrosis despite the presence of the subcostal scar: Type I: When there is a large distance (abdominal closure flap) between the subcostal scar and the cranial incision line of the free flap (width half length), the free flap can be designed in the standard way (Figure 2). If the distance is shorter than this, one of the following types could be used. Type II: When adequate SIE vessels (SIEA diameter 1 mm) are available, the flap is harvested as an SIEA flap or as a DIEP flap but based on low-localised perforators; flap can then be designed more caudal to allow a larger skin bridge. Type III: The flap can be designed using an oblique orientation of the free flap design, which increases the width of the abdominal closure flap (Figure 3). Type IV: When the upper abdominal flap is much smaller or when a chevron scar is present, the flap is skewed as far away from the subcostal scar with the preservation of peri-umbilical perforators to the abdominal closure flap (Figure 4). In the last situation, the skin area caudal to the subcostal scar is left attached to the perforators (Figure 4(b)e(d)). After harvesting the DIEP flap and closing the anterior rectus sheath, the abdominal closure flap is prepared for direct closure of the donor site. Care is taken during undermining to identify a perforating vessel supplying the subcutaneous tissue and skin on the side opposite to the pedicle of the DIEP flap (Figure 4(c)). It is irrelevant whether or not the perforator is on the same side as the
scar, but it is advisable that the perforator is not on the same side as the sacrificed inferior epigastric vessels. The perforator is then dissected to allow abdominal donor site closure without tension on the perforator vessel (Figure 4(d)). The incised fascia is closed directly paying attention to not strangulate the newly positioned perforator. Perforator flap harvesting then proceeds with preservation of the superficial epigastric vein for the option of venous supercharging. The flap is then transferred to the thorax and a conventional end-to-end anastomosis between the inferior epigastric vessels and the internal mammary vessels is performed. Finally, after confirmation of adequate flap perfusion, the flap is inset with appropriate shaping performed. A DIEP or SIEA flap territory includes zone I, II and a variable extension over zone III.16 When a larger flap is required (all three zones or/and zone 4), a contralateral pedicle (either DIE or SIE) is also dissected and a crossover anastomosis is performed between the left and right side of the flap using the continuation of the epigastric vessels and/or a side branch of either epigastric perforator (Figure 4(f)).12
Results Twelve patients, who underwent free abdominal perforator flaps, had previous upper abdominal scars. The time interval between the previous abdominal surgery and free flap breast reconstruction was 6 years on average (range 3e18 years). The patient characteristics are summarised in Table 1. DIEP and SIEA flaps were done in eight and two patients, respectively. A bipedicled flap was used in two patients due to a lack of sufficient lower abdominal pannus.
The SIE vessels were anastomosed to the cranial stump of the DIE vessels (single arrow) and the main DIE pedicle was then anastomosed to the internal mammary vessels (double-arrow). (g). The median part of the chevron scar was release to provide easier closure of the donor site. (h). The outcome at one year postoperatively. The patient had a contralateral mastopexy 3 month later. (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article).
224 One patient had previous liposuction and the other patient had a low body mass index (BMI). In this last patient (Figure 4(d)), two caudal (to subcostal scar) perforators were preserved into the abdominal closure flap after harvesting the DIEP/SIEA flap. One perforator was dissected on each side to allow enough length for flap mobilisation and abdominal closure. Flap design was done as standard or distal planned (types I and II) in four (33.3%) patients each. Types III and IV were performed in only three (25%) and in one case (8.4%), respectively. All flaps survived without complications. Hospital stay was 6 days on average (range 4e7 days). A slight abdominal wound slough occurred in one patient; however, no ischaemia resulted in any of these patients. With a mean follow-up of 5 years and 3 months, there were no further donor site complications.
Discussion Most abdominal scars do not preclude the use of the DIEP flap but may dictate how much tissue is available for use.2,6,8e14 Whereas an appendectomy or a Pfannenstiel scar is usually of no consideration, and may even serve as a ‘delay’,1 a vertical infraumbilical, cholecystectomy or chevron scar may pose a threat to the flap and/or donor site, due to permanent closure of choke vessels.2,8e14 Losken et al. retrospectively reviewed their experience with transverse rectus abdominis myocutaneous (TRAM) flap breast reconstruction in patients with subcostal scars and found an up to 6.5-fold increased risk for skin necrosis on the abdomen compared to patients without previous incisions.5 There were no significant differences in breastrelated complications. Donor site complications were higher with abdominal wall skin necrosis being significantly higher in patients with a subcostal incision (25%) compared with those patients without abdominal wall scars (5%).5 In the literature, other possible solutions to overcome this problem include higher positioning of the abdominal scar or asymmetric skewing of the flap outline. Both techniques may result in a suboptimal abdominal scar position or asymmetry. Takeishi et al. found, in a similar investigation, an eightfold increased complication rate and suggested some flap modification that places the donor scar much higher in the abdomen to avoid such problems.4 In a reply to this article, Weiss17 introduced an asymmetric flap outline to escape the predictable troubles of skin damage at the cephalic wound edge. Our results showed that most of the patients with subcostal scars could still undergo free abdominal flaps for breast reconstruction. Modification to flap design by skewing the flap more distally or obliquely away from the subcostal scar allows safe flap harvesting without abdominal closure flap complications in 91% of the cases. However, preoperative vascular studies using CT scan or Doppler imaging are mandatory to plan the free abdominal flaps. The problem of donor site necrosis in the presence of transverse abdominal scars may be overcome by allowing the abdominal flap to remain pedicled.9 Extensive cranial undermining for donor site closure may compromise its survival. Including the scar within the harvested flap, which can be dissected as a high-designed deep inferior epigastric artery perforator (DIEAP) flap or a pedicled TRAM if the
M. Hamdi et al. contralateral superior epigastric vessels are left intact, could only be done when there are still perforators to the skin and will result in a mid-abdomen horizontal scar. Inspired by perforator flap techniques, we describe a new way to manage this problem. This technique can also be applied in simple abdominoplasty when disturbed microcirculation is anticipated due to subcostal scars in the cephalic portion of the abdominal flap that has to be undermined for wound closure. Preserving one or more of the peri-umbilical perforators may reduce the amount of the harvested flap because the upper part of the DIEP flap will be included in the abdominal closure flap. In this situation, the harvested flap can include the four zones of the lower abdomen. However, a standard flap is perfused by one pedicle but it is not able to vascularise all four zones. To overcome these problems, several techniques can be employed based on experience with midline scars.8,10e14 To increase flap resilience, we described using two pedicles that are interconnected on a side table and combining the SIEA on one side to the DIEP from the other side.12 The interpedicle anastomosis may be performed in any of four patterns.12 In summary, abdominal scars from previous surgeries may influence the harvesting of a perforator flap. Our clinical approach is to try to maximise the perfusion to the upper abdominal flap by either widening/lengthening and or ‘augmenting’ the supply of the upper flap (with perforator preservation). A bipedicled free flap is also an option to provide an adequate amount of tissue when the anatomical condition does not allow harvesting ample tissue using a standard flap.
Authors’ contribution M.H. conceived and designed the new concept and supervised the preparation of the manuscript. M.L. helped in writing the original manuscript. A.Z., B.C. and B.V. provided technical and editing support. All authors discussed the results and implications and commented on the manuscript at all stages.
Conflict of interest None.
Funding None.
References 1. Mahajan AL, Zeltzer A, Claes KE, Van Landuyt K, Hamdi M. Are pfannenstiel scars a boon or a curse for DIEP flap breast reconstructions? Plast Reconstr Surg 2012 Apr;129(4):797e805. 2. Hsieh F, Kumiponjera D, Malata CM. An algorithmic approach to abdominal flap breast reconstruction in patients with preexisting scarseresults from a single surgeon’s experience. J Plast Reconstr Aesthet Surg 2009 Dec;62(12):1650e60. 3. De Frene B, Van Landuyt K, Hamdi M, et al. Free DIEAP and SGAP flap breast reconstruction after abdominal/gluteal liposuction. J Plast Reconstr Aesthet Surg 2006;59(10):1031e6.
Harvesting free abdominal perforator flaps 4. Takeishi M, Shaw WW, Ahn CY, Borud LJ. TRAM flaps in patients with abdominal scars. Plast Reconstr Surg 1997 Mar;99(3): 713e22. 5. Losken A, Carlson GW, Jones GE, Culbertson JH, Schoemann M, Bostwick 3rd J. Importance of right subcostal incisions in patients undergoing TRAM flap breast reconstruction. Ann Plast Surg 2002 Aug;49(2):115e9. 6. Rozen WM, Garcia-Tutor E, Alonso-Burgos A, Corlett RJ, Taylor GI, Ashton MW. The effect of anterior abdominal wall scars on the vascular anatomy of the abdominal wall: a cadaveric and clinical study with clinical implications. Clin Anat 2009 Oct;22(7):815e22. 7. Pennington DG, Nettle WJ, Lam P. Microvascular augmentation of the blood supply of the contralateral side of the free transverse rectus abdominis musculocutaneous flap. Ann Plast Surg 1993 Aug;31(2):123e6. 8. Ali RS, Garrido A, Ramakrishnan V. Stacked free hemi-DIEP flaps: a method of autologous breast reconstruction in a patient with midline abdominal scarring. Br J Plast Surg 2002 Jun; 55(4):351e3. 9. Schoeller T, Huemer GM, Kolehmainen M, Otto-Schoeller A, Wechselberger G. Management of subcostal scars during DIEPflap raising. Br J Plast Surg 2004 Sep;57(6):511e4. 10. Das-Gupta R, Busic V, Begic A. Deep inferior epigastric perforator flap (DIEP) breast reconstruction in the presence of a midline vertical scar. J Plast Reconstr Aesthet Surg 2006;59(6): 675e6.
225 11. Schoeller T, Wechselberger G, Roger J, Hussl H, Huemer GM. Management of infraumbilical vertical scars in DIEP-flaps by crossover anastomosis. J Plast Reconstr Aesthet Surg 2007;60: 524e8. 12. Hamdi M, Khuthaila DK, Van Landuyt K, Roche N, Monstrey S. Double-pedicle abdominal perforator free flaps for unilateral breast reconstruction: new horizons in microsurgical tissue transfer to the breast. J Plast Reconstr Aesthet Surg 2007; 60(8):904e12. 13. Beahm EK, Walton RL. The efficacy of bilateral lower abdominal free flaps for unilateral breast reconstruction. Plast Reconstr Surg 2007 Jul;120(1):41e54. 14. Rabey NG, Erel E, Malata CM. Double-pedicled abdominal free flap using an entirely new microvascular combination of DIEP and SIEA vascular pedicles for unilateral breast reconstruction: a novel addition to the Hamdi classification. Plast Reconstr Surg 2012 Nov;130(5):767ee9e. 15. Hamdi M, Van Landuyt K, Van Hedent E, Duyck P. Advances in autogenous breast reconstruction: the role of preoperative perforator mapping. Ann Plast Surg 2007 Jan;58(1):18e26. 16. Holm C, Mayr M, Ho ¨fter E, Ninkovic M. Perfusion zones of the DIEP flap revisited: a clinical study. Plast Reconstr Surg 2006 Jan;117(1):37e43. 17. Weiss PR. TRAM flap breast reconstruction in patients with previous abdominal scars. Plast Reconstr Surg 1999 Mar; 103(3):1100e1.
