Annals of Plastic Surgery • Volume 74, Number 6, June 2015
Letter to the Editor
Identification of the omohyoid muscle laterally and medially facilitates safe identification of the pedicle. Moreover, the transverse cervical artery origin can be variable and the operating surgeon must be mindful of this during dissection. Finally, we have found this flap harvest to be extremely reliable with early success and have not needed to use any dyes to confirm viability. We remain excited that many groups continue to work toward improving our ability to transfer lymph nodes successfully and help patients with this truly potentially devastating condition.
Stamatis Sapountzis, MD Dhruv Singhal, MD Pedro Ciudad, MD Domenico Meo, MD Hung Chi Chen, MD, PhD, FACS Department of Plastic and Reconstructive Surgery China Medical University Hospital Taichung, Taiwan [email protected] REFERENCES 1. Sapountzis S, Singhal D, Rashid A, et al. Lymph node flap based on the right transverse cervical artery as a donor site for lymph node transfer. Ann Plast Surg. 2014;73:398–401. 2. Althubaiti GA, Crosby MA, Chang DW. Vascularized supraclavicular lymph node transfer for lower extremity lymphedema treatment. Plast Reconstr Surg. 2013;131:133e–135e. 3. Becker C, Vasile JV, Levine JL, et al. Microlymphatic surgery for the treatment of iatrogenic lymphedema. Clin Plast Surg. 2012;39:385–398.
Paramuscular Perforators in DIEAP Flap for Breast Reconstruction An Important Variation in Perforator Flap Nomenclature To the Editor: he group from the Hospital de la Santa Creu I Sant Pau in a retrospective review of their multidetector row computed tomography used for preoperative planning for abdominal breast reconstruction over a period of 8 years found a high incidence of a single, dominant so-called paramuscular perforator.1 They have succinctly presented extremely
T
Received November 30, 2014, and accepted for publication, after revision, March 16, 2015 Conflict of interest and sources of funding: none declared. Presented at the 15th International Course on Preforator Flaps, New York, November 22, 2013, and 16th International Course on Perforator Flaps, Ningbo, China, November 9, 2014. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0148-7043/15/7406-0745 DOI: 10.1097/SAP.0000000000000535
FIGURE 1. Modified from Nakajima et al2 Figure 2, showing their “six patterns of the vascular supply to the fasciocutaneous plexus.” The dotted circle encompasses the vascular pedicle at the hilum of a muscle, where their type “C” branch arises from that muscle source vessel just before the latter enters the muscle. Note that type “C” is their “direct cutaneous branch of muscular vessel,” or more simply today, a “paramuscular” perforator.
valuable data for anyone performing DIEAP flap surgery, noting that this perforator courses around the medial border of the rectus abdominis muscle after arising from the medial branch of the deep inferior epigastric vessels, with a total retromuscular course. It ultimately pierces the anterior rectus sheath lateral to the linea alba and eventually reaches the subdermal plexus. Muscle function will always be totally preserved because there is no need for any muscle dissection, and the more laterally located motor nerves are always avoided. As would be anticipated, flap harvest time should thereby also be expedited to make this usually large caliber perforator a more efficient choice. An historical overview of the evolution of this important topic is thus warranted. Interestingly, Nakajima et al2 predicted in this journal as early as 1986 the existence of what they called a “direct cutaneous branch of muscular vessel.” Exiting from the hilum of the source vessel to a muscle just before the latter entering that muscle (Fig. 1), these branches course around that same muscle to then pierce the deep fascia and continue onto the skin. Vandevoort et al3 called them “paramedian” perforators in their review of the topography of DIEAP flaps that were to be used for breast reconstruction. Chen and Allen,4 and the Group for the Advancement of Breast Reconstruction,5 instead applied the appellation “septocutaneous” perforator following the suggestion of the Gent nomenclature that perforator flaps must be direct perforator flaps, muscle perforator flaps, or septal perforator flaps.6 Presumably, for the same reason, the Barcelona group concluded that their “paramuscular perforator can be considered a septal perforator because it traverses the intermuscular septum only to supply the overlying tissue.1”
© 2015 Wolters Kluwer Health, Inc. All rights reserved.
Yet remembering our common introduction to basic anatomy, an intermuscular septum was defined as a “lamina of deep fascia which extends between and encloses muscle groups.7” One must also acknowledge that the sheath surrounding the rectus abdominis muscle is formed by the fusion and/or separation of the aponeuroses of the internal and external abdominal oblique muscles and transversus abdominis muscle.8 An aponeuroses is a sheet-like tendon and not a septum at all.9 Therefore, these “paramuscular” perforators are neither septal nor muscular perforators as they do not pass through a “true” septum nor muscle,10 and as Nakajima et al2 had postulated would represent a fourth important type of perforator flap that requires its own unique approach to perforator identification and surgical dissection. Gravvanis et al11 made an important contribution in regard to this terminology. Indeed, these are paramuscular perforators, supplying paramuscular perforator flaps, and should be called such.
Geoffrey G. Hallock, MD Division of Plastic Surgery Sacred Heart and Lehigh Valley Hospitals Allentown, Pennsylvania St. Luke's Hospital Bethlehem, PA [email protected]
REFERENCES 1. Pons G, Masia J, Sanchez-Porro L, et al. Paramuscular perforators in DIEAP flap for breast reconstruction. Ann Plast Surg. 2014;73:659–661. 2. Nakajima H, Fujino T, Adachi S. A new concept of vascular supply to the skin and classification of skin
www.annalsplasticsurgery.com
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
745
Annals of Plastic Surgery • Volume 74, Number 6, June 2015
Letter to the Editor
3.
4.
5.
6.
7.
8.
9.
10.
11.
flaps according to their vascularization. Ann Plast Surg. 1986;16:1–19. Vandevoort M, Vranckx JJ, Fabre G. Perforator topography of the deep inferior epigastric perforator flap in 100 cases of breast reconstruction. Plast Reconstr Surg. 2002;109:1912–1918. Chen CM, Allen RJ. Breast reconstruction with the septocutaneous perforator flap: the next frontier. Plast Reconstr Surg. 2009;124(Suppl 2):S680. Massey MF, Spiegel AJ, Levine JL, et al. for the Group for the Advancement of Breast Reconstruction. Perforator flaps: recent experience, current trends, and future directions based on 3974 microsurgical breast reconstructions. Plast Reconstr Surg. 2009;124:737–751. Blondeel PN, Van Landuyt KHI, Monstrey SJM, et al. The “Gent” consensus on perforator flap terminology: preliminary definitions. Plast Reconstr Surg. 2003;112:1378–1382. Woodburne RT. Editor, Essentials of Human Anatomy. 4th ed. New York: Oxford University Press, New York; 1969:15–17. Woodburne RT. Editor, Essentials of Human Anatomy. 4th ed. New York: Oxford University Press, New York; 1969:366. Woodburne RT. Editor, Essentials of Human Anatomy. 4th ed. New York: Oxford University Press, New York; 1969:11. Neligan PC, Blondeel PN, Morris SF, et al. Perforator Flaps: Overview, Classification, and Nomenclature. In: Blondeel PN, Morris SF, Hallock GG, Neligan PC, eds. Perforator Flaps: Anatomy, Technique, & Clinical Applications. Second ed. St. Louis, Missouri: Quality Medical Publishing; 2013: 59–60. Gravvanis A, Dionyssiou DD, Chandrasekharan L, et al. Paramuscular and paraneural perforators in DIEAP flaps: radiographic findings and clinical application. Ann Plast Surg. 2009;63:610–615.
746
www.annalsplasticsurgery.com
Paramuscular Perforators in Dieap Flap for Breast Reconstruction An Important Variation in Perforator Flap Nomenclature: Reply
W
e thank Dr Hallock both for the exquisite anatomical description and accurate discussion about paramuscular perforators, as well as clarifying a very important point which we have also tried to illustrate in our article.1 We agree that paramuscular perforators meet all the criteria that enable them to be considered as a “direct cutaneous branch of muscular vessel” in keeping with Nakajima's definition.2 There is no doubt, according to the strict anatomical description highlighted by Dr Hallock, that these perforators cannot be defined as paraseptal, given that the sheath surrounding
the rectus abdominis muscle is in fact formed by aponeuroses and not a real septum. Although in our article, we have attempted to categorize these paramuscular perforators within the terminology consensus set in Gent,3 we acknowledge our error in considering these perforators as paraseptal. Indeed, as pointed out by Dr Hallock, the morphological features and particular course of paramuscular perforators clearly differentiate them from muscular and septocutaneous perforators and make them worthy of their own nomenclature.
Gemma Pons, MD Department of Plastic and Reconstructive Surgery Hospital de la Santa Creu i Sant Pau Universitat Autònoma de Barcelona Barcelona, Spain [email protected].
REFERENCES Received February 13, 2015, and accepted for publication, after revision, March 16, 2015. Conflicts of interest and sources of funding: none declared. Reprints: Gemma Pons, MD, Department of Plastic and Reconstructive Surgery, Hospital de la Santa Creu i Sant Pau, Universitat Autòmoma de Barcelona, Sant Quintí 89, 08041 Barcelona, Spain. E-mail: [email protected]. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0148-7043/15/7406-0746 DOI: 10.1097/SAP.0000000000000536
1. Pons G, Masia J, Sanchez-Porro L, et al. Paramuscular perforators in DIEAP flap for breast reconstruction. Ann Plast Surg. 2014;73:659–661. 2. Nakajima H, Fujino T, Adachi S. A new concept of vascular supply to the skin and classification of skin flaps according to their vascularization. Ann Plast Surg. 1986;16:1–19. 3. Blondeel PN, Van Landuyt KHI, Monstrey SJM, et al. The “Gent” consensus on perforator flap terminology: preliminary definitions. Plast Reconstr Surg. 2003;112:1378–1382.
© 2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Letter to the Editor
Identification of the omohyoid muscle laterally and medially facilitates safe identification of the pedicle. Moreover, the transverse cervical artery origin can be variable and the operating surgeon must be mindful of this during dissection. Finally, we have found this flap harvest to be extremely reliable with early success and have not needed to use any dyes to confirm viability. We remain excited that many groups continue to work toward improving our ability to transfer lymph nodes successfully and help patients with this truly potentially devastating condition.
Stamatis Sapountzis, MD Dhruv Singhal, MD Pedro Ciudad, MD Domenico Meo, MD Hung Chi Chen, MD, PhD, FACS Department of Plastic and Reconstructive Surgery China Medical University Hospital Taichung, Taiwan [email protected] REFERENCES 1. Sapountzis S, Singhal D, Rashid A, et al. Lymph node flap based on the right transverse cervical artery as a donor site for lymph node transfer. Ann Plast Surg. 2014;73:398–401. 2. Althubaiti GA, Crosby MA, Chang DW. Vascularized supraclavicular lymph node transfer for lower extremity lymphedema treatment. Plast Reconstr Surg. 2013;131:133e–135e. 3. Becker C, Vasile JV, Levine JL, et al. Microlymphatic surgery for the treatment of iatrogenic lymphedema. Clin Plast Surg. 2012;39:385–398.
Paramuscular Perforators in DIEAP Flap for Breast Reconstruction An Important Variation in Perforator Flap Nomenclature To the Editor: he group from the Hospital de la Santa Creu I Sant Pau in a retrospective review of their multidetector row computed tomography used for preoperative planning for abdominal breast reconstruction over a period of 8 years found a high incidence of a single, dominant so-called paramuscular perforator.1 They have succinctly presented extremely
T
Received November 30, 2014, and accepted for publication, after revision, March 16, 2015 Conflict of interest and sources of funding: none declared. Presented at the 15th International Course on Preforator Flaps, New York, November 22, 2013, and 16th International Course on Perforator Flaps, Ningbo, China, November 9, 2014. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0148-7043/15/7406-0745 DOI: 10.1097/SAP.0000000000000535
FIGURE 1. Modified from Nakajima et al2 Figure 2, showing their “six patterns of the vascular supply to the fasciocutaneous plexus.” The dotted circle encompasses the vascular pedicle at the hilum of a muscle, where their type “C” branch arises from that muscle source vessel just before the latter enters the muscle. Note that type “C” is their “direct cutaneous branch of muscular vessel,” or more simply today, a “paramuscular” perforator.
valuable data for anyone performing DIEAP flap surgery, noting that this perforator courses around the medial border of the rectus abdominis muscle after arising from the medial branch of the deep inferior epigastric vessels, with a total retromuscular course. It ultimately pierces the anterior rectus sheath lateral to the linea alba and eventually reaches the subdermal plexus. Muscle function will always be totally preserved because there is no need for any muscle dissection, and the more laterally located motor nerves are always avoided. As would be anticipated, flap harvest time should thereby also be expedited to make this usually large caliber perforator a more efficient choice. An historical overview of the evolution of this important topic is thus warranted. Interestingly, Nakajima et al2 predicted in this journal as early as 1986 the existence of what they called a “direct cutaneous branch of muscular vessel.” Exiting from the hilum of the source vessel to a muscle just before the latter entering that muscle (Fig. 1), these branches course around that same muscle to then pierce the deep fascia and continue onto the skin. Vandevoort et al3 called them “paramedian” perforators in their review of the topography of DIEAP flaps that were to be used for breast reconstruction. Chen and Allen,4 and the Group for the Advancement of Breast Reconstruction,5 instead applied the appellation “septocutaneous” perforator following the suggestion of the Gent nomenclature that perforator flaps must be direct perforator flaps, muscle perforator flaps, or septal perforator flaps.6 Presumably, for the same reason, the Barcelona group concluded that their “paramuscular perforator can be considered a septal perforator because it traverses the intermuscular septum only to supply the overlying tissue.1”
© 2015 Wolters Kluwer Health, Inc. All rights reserved.
Yet remembering our common introduction to basic anatomy, an intermuscular septum was defined as a “lamina of deep fascia which extends between and encloses muscle groups.7” One must also acknowledge that the sheath surrounding the rectus abdominis muscle is formed by the fusion and/or separation of the aponeuroses of the internal and external abdominal oblique muscles and transversus abdominis muscle.8 An aponeuroses is a sheet-like tendon and not a septum at all.9 Therefore, these “paramuscular” perforators are neither septal nor muscular perforators as they do not pass through a “true” septum nor muscle,10 and as Nakajima et al2 had postulated would represent a fourth important type of perforator flap that requires its own unique approach to perforator identification and surgical dissection. Gravvanis et al11 made an important contribution in regard to this terminology. Indeed, these are paramuscular perforators, supplying paramuscular perforator flaps, and should be called such.
Geoffrey G. Hallock, MD Division of Plastic Surgery Sacred Heart and Lehigh Valley Hospitals Allentown, Pennsylvania St. Luke's Hospital Bethlehem, PA [email protected]
REFERENCES 1. Pons G, Masia J, Sanchez-Porro L, et al. Paramuscular perforators in DIEAP flap for breast reconstruction. Ann Plast Surg. 2014;73:659–661. 2. Nakajima H, Fujino T, Adachi S. A new concept of vascular supply to the skin and classification of skin
www.annalsplasticsurgery.com
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
745
Annals of Plastic Surgery • Volume 74, Number 6, June 2015
Letter to the Editor
3.
4.
5.
6.
7.
8.
9.
10.
11.
flaps according to their vascularization. Ann Plast Surg. 1986;16:1–19. Vandevoort M, Vranckx JJ, Fabre G. Perforator topography of the deep inferior epigastric perforator flap in 100 cases of breast reconstruction. Plast Reconstr Surg. 2002;109:1912–1918. Chen CM, Allen RJ. Breast reconstruction with the septocutaneous perforator flap: the next frontier. Plast Reconstr Surg. 2009;124(Suppl 2):S680. Massey MF, Spiegel AJ, Levine JL, et al. for the Group for the Advancement of Breast Reconstruction. Perforator flaps: recent experience, current trends, and future directions based on 3974 microsurgical breast reconstructions. Plast Reconstr Surg. 2009;124:737–751. Blondeel PN, Van Landuyt KHI, Monstrey SJM, et al. The “Gent” consensus on perforator flap terminology: preliminary definitions. Plast Reconstr Surg. 2003;112:1378–1382. Woodburne RT. Editor, Essentials of Human Anatomy. 4th ed. New York: Oxford University Press, New York; 1969:15–17. Woodburne RT. Editor, Essentials of Human Anatomy. 4th ed. New York: Oxford University Press, New York; 1969:366. Woodburne RT. Editor, Essentials of Human Anatomy. 4th ed. New York: Oxford University Press, New York; 1969:11. Neligan PC, Blondeel PN, Morris SF, et al. Perforator Flaps: Overview, Classification, and Nomenclature. In: Blondeel PN, Morris SF, Hallock GG, Neligan PC, eds. Perforator Flaps: Anatomy, Technique, & Clinical Applications. Second ed. St. Louis, Missouri: Quality Medical Publishing; 2013: 59–60. Gravvanis A, Dionyssiou DD, Chandrasekharan L, et al. Paramuscular and paraneural perforators in DIEAP flaps: radiographic findings and clinical application. Ann Plast Surg. 2009;63:610–615.
746
www.annalsplasticsurgery.com
Paramuscular Perforators in Dieap Flap for Breast Reconstruction An Important Variation in Perforator Flap Nomenclature: Reply
W
e thank Dr Hallock both for the exquisite anatomical description and accurate discussion about paramuscular perforators, as well as clarifying a very important point which we have also tried to illustrate in our article.1 We agree that paramuscular perforators meet all the criteria that enable them to be considered as a “direct cutaneous branch of muscular vessel” in keeping with Nakajima's definition.2 There is no doubt, according to the strict anatomical description highlighted by Dr Hallock, that these perforators cannot be defined as paraseptal, given that the sheath surrounding
the rectus abdominis muscle is in fact formed by aponeuroses and not a real septum. Although in our article, we have attempted to categorize these paramuscular perforators within the terminology consensus set in Gent,3 we acknowledge our error in considering these perforators as paraseptal. Indeed, as pointed out by Dr Hallock, the morphological features and particular course of paramuscular perforators clearly differentiate them from muscular and septocutaneous perforators and make them worthy of their own nomenclature.
Gemma Pons, MD Department of Plastic and Reconstructive Surgery Hospital de la Santa Creu i Sant Pau Universitat Autònoma de Barcelona Barcelona, Spain [email protected].
REFERENCES Received February 13, 2015, and accepted for publication, after revision, March 16, 2015. Conflicts of interest and sources of funding: none declared. Reprints: Gemma Pons, MD, Department of Plastic and Reconstructive Surgery, Hospital de la Santa Creu i Sant Pau, Universitat Autòmoma de Barcelona, Sant Quintí 89, 08041 Barcelona, Spain. E-mail: [email protected]. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0148-7043/15/7406-0746 DOI: 10.1097/SAP.0000000000000536
1. Pons G, Masia J, Sanchez-Porro L, et al. Paramuscular perforators in DIEAP flap for breast reconstruction. Ann Plast Surg. 2014;73:659–661. 2. Nakajima H, Fujino T, Adachi S. A new concept of vascular supply to the skin and classification of skin flaps according to their vascularization. Ann Plast Surg. 1986;16:1–19. 3. Blondeel PN, Van Landuyt KHI, Monstrey SJM, et al. The “Gent” consensus on perforator flap terminology: preliminary definitions. Plast Reconstr Surg. 2003;112:1378–1382.
© 2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
