Plastic and Reconstructive Surgery • June 2015
Fig. 1. The perforator-to-perforator anastomosis in a DIEP flap. Artery (A) and vein (V) were repaired using the simple interrupted suture with 10-0 nylon. In this case, the flap was based on another safe perforator, but we were not sure about the vascularization of the flap, so we decided to perform the anastomosis of the perforator accidentally injured to obtain a two-perforator–based flap (original magnification, × 10). University of Catania Cannizzaro Hospital Via Messina, 829 95126 Catania, Italy [email protected]
disclosure The authors have no financial interest to declare in relation to the content of this communication. references 1. Ireton JE, Lakhiani C, Saint-Cyr M. Vascular anatomy of the deep inferior epigastric artery perforator flap: A systematic review. Plast Reconstr Surg. 2014;134:810e–821e. 2. Wong C, Saint-Cyr M, Arbique G, et al. Three- and fourdimensional computed tomography angiographic studies of commonly used abdominal flaps in breast reconstruction. Plast Reconstr Surg. 2009;124:18–27. 3. Saint-Cyr M, Wong C, Schaverien M, Mojallal A, Rohrich RJ. The perforasome theory: Vascular anatomy and clinical implications. Plast Reconstr Surg. 2009;124:1529–1544. 4. Miyamoto S, Sakuraba M, Nagamatsu S. Inadvertent injury of critical perforator vessels during perforator flap surgery. J Reconstr Microsurg. 2012;28:95–98. 5. Hong JP. The use of supermicrosurgery in lower extremity reconstruction: The next step in evolution. Plast Reconstr Surg. 2009;123:230–235.
Reply: How Many Perforators in a Deep Inferior Epigastric Artery Perforator Flap? The Salvage of a Perforator Sir:
We would like to thank Dr. Lombardo and colleagues for their interest in our recent article entitled “Vascular Anatomy of the Deep Inferior Epigastric Artery
Perforator Flap: A Systematic Review.”1 The authors are to be congratulated for their elegant case presentation where deep inferior epigastric artery perforator (DIEP) flap vascularity was augmented by anastomosing a nonintended (and previously injured) perforator to the intended DIEP flap perforator. The authors also point out key steps to follow in the event of a DIEP flap perforator injury during dissection. Another option to add to this list would be the use of the superficial inferior epigastric vein/artery system. The superficial inferior epigastric artery flap can be used as a bailout in cases of irreparable perforator injury or inability to convert to a muscle-sparing transverse rectus abdominis myocutaneous flap in bilateral cases. A simple and safe approach to DIEP flap harvest includes the early identification of the most dominant perforator within the DIEP flap. We perform almost exclusively bilateral DIEP flaps, and identification of the single most dominant perforator within the hemi abdomen is essential not only for arterial perfusion but, most importantly, for venous outflow. This also allows the ability to harvest hemi-DIEP flaps based on a single perforator only. Once the dominant perforator is identified, either from the lateral or medial row, dissection is carried out as usual. The uninvolved row (e.g., entire lateral row if a medial row perforator is selected) is not dissected and kept intact in case of injury. Keeping the opposite row intact and nondissected saves time, avoids traction injury while dissecting the dominant perforator, and leaves the option of using additional perforators or converting to a muscle-sparing transverse rectus abdominis myocutaneous if perforators are too small. Preoperative computed tomography can help identify the most radiologically dominant perforator, and we certainly agree with the authors that radiologic dominance is static and should always be confirmed with realtime in vivo perfusion dominance. When preoperative
1056e Copyright © 2015 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Volume 135, Number 6 • Letters computed tomography is not used, dissection of the lateral row is quickly performed first to identify a suitable perforator. If the lateral row does not yield a dominant perforator, the periumbilical region is dissected and will usually yield one, within 5 cm from the umbilicus. As mentioned by Lombardo et al., the advent of supermicrosurgery allows for tremendous plasticity in perforator selection and incorporation within flaps that require additional arterial and/or venous perfusion. Another option, which is simple and relatively fast, is to dissect an adjacent perforator(s) for a short intramuscular course (e.g., from the opposite row) and keep the closest pedicle recipient side branch as long as possible for use as a potential recipient vessel. This allows the use of perforators from both the lateral and medial rows without sacrificing rectus muscle. In certain cases, this additional perforator can even be used as the main flap perforator and directly anastomosed to the recipient vessels. Although highlighted here in the DIEP flap, the option for additional perforator-to-perforator anastomosis should be considered and kept in mind in all other perforator flap dissections when needed.2–4 DOI: 10.1097/PRS.0000000000001298
Michel Saint-Cyr, M.D. Mayo Clinic Rochester, Minn.
Jordan E. Ireton, M.D. Department of Plastic Surgery University of Texas Southwestern Medical Center Dallas, Tx.
Chrisovalantis Lakhiani, M.D. Department of Plastic Surgery Georgetown University Hospital Washington, D.C. Correspondence to Dr. Saint-Cyr Division of Plastic Surgery Mayo Clinic 200 First Street S.W. Rochester, Minn. 55905 [email protected]
DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication. REFERENCES 1. Ireton JE, Lakhiani C, Saint-Cyr M. Vascular anatomy of the deep inferior epigastric artery perforator flap: A systematic review. Plast Reconstr Surg. 2014;134:810e–821e. 2. Wong C, Saint-Cyr M, Arbique G, et al. Three- and fourdimensional computed tomography angiographic studies of commonly used abdominal flaps in breast reconstruction. Plast Reconstr Surg. 2009;124:18–27. 3. Saint-Cyr M, Wong C, Schaverien M, Mojallal A, Rohrich RJ. The perforasome theory: Vascular anatomy and clinical implications. Plast Reconstr Surg. 2009;124:1529–1544. 4. Koshima I, Yamamoto T, Narushima M, Mihara M, Iida T. Perforator flaps and supermicrosurgery. Clin Plast Surg. 2010;37:683–689.
Chronic Biofilm Infection in Breast Implants Is Associated with an Increased T-Cell Lymphocytic Infiltrate: Implications for Breast Implant–Associated Lymphoma Sir:
G
iven the recent reports concerning the findings of anaplastic large cell lymphoma (ALCL) of the breast that have been noted to occur in association with breast implants,1 the findings of this article looking at the association of chronic biofilm with a T-cell lymphocytic response2 certainly merit careful study. To summarize, the authors have used an established biofilm model in the pig to measure not only the bacterial load but also the lymphatic cell response to this infectious challenge in the surrounding capsule and the surface of the implant. Also, capsular specimens from patients afflicted with Baker grade IV capsular contracture were analyzed for the same variables. To summarize, in the pig, a larger bacterial load was noted to be present on the surface of textured versus smooth implants, and this was associated with a greater number of lymphocytes, most of which were T cells. When these T cells were examined using scanning electron microscopy, they had the appearance of being activated. In addition, when the human tissue was examined, an inflammatory response was identified, and it was predominantly a T-cell infiltrate. Also, using linear regression analysis, there appeared to be a direct correlation between the number of lymphocytes and the number of bacteria in the capsule. In light of these findings, a potential causal link between biofilm formation, inflammation, T-cell proliferation, and finally the potential for degeneration into ALCL is discussed. Beyond this, the authors, who have a great interest in and an extensive experience with evaluating for biofilms, interpret their data as supporting a hypothesis that a greater bacterial load can lead to increasing severity of capsular contracture. This is shown in their pig data, where the implants associated with the more severely contracted capsules demonstrated a higher bacterial count. Also, all of the Baker grade IV human capsular tissue studied demonstrated the presence of biofilm, with more aggressive textures showing greater amounts of bacteria. It should be noted that all of these specimens were obtained from textured implant patients; no specimen was obtained from smooth-walled devices. Given this outline, several points merit specific comment. This study is hampered by low numbers. The Baker grade IV capsular data points in the pig were generated from only three of the 20 implants that form the basis of the study. Also, when the actual capsular tissue specimens in the pigs were examined, no significant difference in bacterial load between textured and smooth implants could be identified despite a trend that appeared to be supportive. In addition, there was no significant difference in the number of lymphocytes in the pig capsular tissue when comparing pockets containing smooth versus textured implants. It would be reasonable to hypothesize that it
1057e Copyright © 2015 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Fig. 1. The perforator-to-perforator anastomosis in a DIEP flap. Artery (A) and vein (V) were repaired using the simple interrupted suture with 10-0 nylon. In this case, the flap was based on another safe perforator, but we were not sure about the vascularization of the flap, so we decided to perform the anastomosis of the perforator accidentally injured to obtain a two-perforator–based flap (original magnification, × 10). University of Catania Cannizzaro Hospital Via Messina, 829 95126 Catania, Italy [email protected]
disclosure The authors have no financial interest to declare in relation to the content of this communication. references 1. Ireton JE, Lakhiani C, Saint-Cyr M. Vascular anatomy of the deep inferior epigastric artery perforator flap: A systematic review. Plast Reconstr Surg. 2014;134:810e–821e. 2. Wong C, Saint-Cyr M, Arbique G, et al. Three- and fourdimensional computed tomography angiographic studies of commonly used abdominal flaps in breast reconstruction. Plast Reconstr Surg. 2009;124:18–27. 3. Saint-Cyr M, Wong C, Schaverien M, Mojallal A, Rohrich RJ. The perforasome theory: Vascular anatomy and clinical implications. Plast Reconstr Surg. 2009;124:1529–1544. 4. Miyamoto S, Sakuraba M, Nagamatsu S. Inadvertent injury of critical perforator vessels during perforator flap surgery. J Reconstr Microsurg. 2012;28:95–98. 5. Hong JP. The use of supermicrosurgery in lower extremity reconstruction: The next step in evolution. Plast Reconstr Surg. 2009;123:230–235.
Reply: How Many Perforators in a Deep Inferior Epigastric Artery Perforator Flap? The Salvage of a Perforator Sir:
We would like to thank Dr. Lombardo and colleagues for their interest in our recent article entitled “Vascular Anatomy of the Deep Inferior Epigastric Artery
Perforator Flap: A Systematic Review.”1 The authors are to be congratulated for their elegant case presentation where deep inferior epigastric artery perforator (DIEP) flap vascularity was augmented by anastomosing a nonintended (and previously injured) perforator to the intended DIEP flap perforator. The authors also point out key steps to follow in the event of a DIEP flap perforator injury during dissection. Another option to add to this list would be the use of the superficial inferior epigastric vein/artery system. The superficial inferior epigastric artery flap can be used as a bailout in cases of irreparable perforator injury or inability to convert to a muscle-sparing transverse rectus abdominis myocutaneous flap in bilateral cases. A simple and safe approach to DIEP flap harvest includes the early identification of the most dominant perforator within the DIEP flap. We perform almost exclusively bilateral DIEP flaps, and identification of the single most dominant perforator within the hemi abdomen is essential not only for arterial perfusion but, most importantly, for venous outflow. This also allows the ability to harvest hemi-DIEP flaps based on a single perforator only. Once the dominant perforator is identified, either from the lateral or medial row, dissection is carried out as usual. The uninvolved row (e.g., entire lateral row if a medial row perforator is selected) is not dissected and kept intact in case of injury. Keeping the opposite row intact and nondissected saves time, avoids traction injury while dissecting the dominant perforator, and leaves the option of using additional perforators or converting to a muscle-sparing transverse rectus abdominis myocutaneous if perforators are too small. Preoperative computed tomography can help identify the most radiologically dominant perforator, and we certainly agree with the authors that radiologic dominance is static and should always be confirmed with realtime in vivo perfusion dominance. When preoperative
1056e Copyright © 2015 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Volume 135, Number 6 • Letters computed tomography is not used, dissection of the lateral row is quickly performed first to identify a suitable perforator. If the lateral row does not yield a dominant perforator, the periumbilical region is dissected and will usually yield one, within 5 cm from the umbilicus. As mentioned by Lombardo et al., the advent of supermicrosurgery allows for tremendous plasticity in perforator selection and incorporation within flaps that require additional arterial and/or venous perfusion. Another option, which is simple and relatively fast, is to dissect an adjacent perforator(s) for a short intramuscular course (e.g., from the opposite row) and keep the closest pedicle recipient side branch as long as possible for use as a potential recipient vessel. This allows the use of perforators from both the lateral and medial rows without sacrificing rectus muscle. In certain cases, this additional perforator can even be used as the main flap perforator and directly anastomosed to the recipient vessels. Although highlighted here in the DIEP flap, the option for additional perforator-to-perforator anastomosis should be considered and kept in mind in all other perforator flap dissections when needed.2–4 DOI: 10.1097/PRS.0000000000001298
Michel Saint-Cyr, M.D. Mayo Clinic Rochester, Minn.
Jordan E. Ireton, M.D. Department of Plastic Surgery University of Texas Southwestern Medical Center Dallas, Tx.
Chrisovalantis Lakhiani, M.D. Department of Plastic Surgery Georgetown University Hospital Washington, D.C. Correspondence to Dr. Saint-Cyr Division of Plastic Surgery Mayo Clinic 200 First Street S.W. Rochester, Minn. 55905 [email protected]
DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication. REFERENCES 1. Ireton JE, Lakhiani C, Saint-Cyr M. Vascular anatomy of the deep inferior epigastric artery perforator flap: A systematic review. Plast Reconstr Surg. 2014;134:810e–821e. 2. Wong C, Saint-Cyr M, Arbique G, et al. Three- and fourdimensional computed tomography angiographic studies of commonly used abdominal flaps in breast reconstruction. Plast Reconstr Surg. 2009;124:18–27. 3. Saint-Cyr M, Wong C, Schaverien M, Mojallal A, Rohrich RJ. The perforasome theory: Vascular anatomy and clinical implications. Plast Reconstr Surg. 2009;124:1529–1544. 4. Koshima I, Yamamoto T, Narushima M, Mihara M, Iida T. Perforator flaps and supermicrosurgery. Clin Plast Surg. 2010;37:683–689.
Chronic Biofilm Infection in Breast Implants Is Associated with an Increased T-Cell Lymphocytic Infiltrate: Implications for Breast Implant–Associated Lymphoma Sir:
G
iven the recent reports concerning the findings of anaplastic large cell lymphoma (ALCL) of the breast that have been noted to occur in association with breast implants,1 the findings of this article looking at the association of chronic biofilm with a T-cell lymphocytic response2 certainly merit careful study. To summarize, the authors have used an established biofilm model in the pig to measure not only the bacterial load but also the lymphatic cell response to this infectious challenge in the surrounding capsule and the surface of the implant. Also, capsular specimens from patients afflicted with Baker grade IV capsular contracture were analyzed for the same variables. To summarize, in the pig, a larger bacterial load was noted to be present on the surface of textured versus smooth implants, and this was associated with a greater number of lymphocytes, most of which were T cells. When these T cells were examined using scanning electron microscopy, they had the appearance of being activated. In addition, when the human tissue was examined, an inflammatory response was identified, and it was predominantly a T-cell infiltrate. Also, using linear regression analysis, there appeared to be a direct correlation between the number of lymphocytes and the number of bacteria in the capsule. In light of these findings, a potential causal link between biofilm formation, inflammation, T-cell proliferation, and finally the potential for degeneration into ALCL is discussed. Beyond this, the authors, who have a great interest in and an extensive experience with evaluating for biofilms, interpret their data as supporting a hypothesis that a greater bacterial load can lead to increasing severity of capsular contracture. This is shown in their pig data, where the implants associated with the more severely contracted capsules demonstrated a higher bacterial count. Also, all of the Baker grade IV human capsular tissue studied demonstrated the presence of biofilm, with more aggressive textures showing greater amounts of bacteria. It should be noted that all of these specimens were obtained from textured implant patients; no specimen was obtained from smooth-walled devices. Given this outline, several points merit specific comment. This study is hampered by low numbers. The Baker grade IV capsular data points in the pig were generated from only three of the 20 implants that form the basis of the study. Also, when the actual capsular tissue specimens in the pigs were examined, no significant difference in bacterial load between textured and smooth implants could be identified despite a trend that appeared to be supportive. In addition, there was no significant difference in the number of lymphocytes in the pig capsular tissue when comparing pockets containing smooth versus textured implants. It would be reasonable to hypothesize that it
1057e Copyright © 2015 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
