Plastic and Reconstructive Surgery • November 2013 We studied the effect of radiation on not only the arteries but also the veins. As a control, we analyzed the epigastric vessels, easily accessible during the dissection of the flap. Our preliminary results on 10 patients suggest significant lesions on the internal mammary vessels caused by radiotherapy. Clinically, we often noticed a greater tonus and a better parietal quality for retrocostal vessels (Fig. 1). Histologically, we systematically highlighted a difference of parietal integrity between the intercostal and retrocostal segments of internal mammary vessels (Fig. 2). The first presented a complete dissociation of elastic fibers, with a parietal ischemia dissociating the vascular wall, associated with a hyalinization. Some local microthrombi were also frequently noticeable. The veins appear to have been affected by radiotherapy in the same way. Retrocostal segments presented an internal elastic lamina partially dissociated with hyperplasia of the tunica media, but the integrity of the wall was generally better preserved. Moreover, the vascular lumen remained consistently better preserved. Thus, this study can be applied not only for the intercostal segment of the internal mammary vessels but also for its perforators. Some authors have already reported the possibility of their use for anastomoses.3,4 These preliminary results do not allow us to identify a causal relationship between a pejorative histology and the risk of failure of microsurgery. However, the rib undeniably seems to have a protective role in radiotherapy of the blood vessels. The radiation damage results in impaired parietal tonus and laminar flow, which can be prothrombotic. Therefore, we prefer to avoid using the intercostal segment for anastomoses of the free flap and advocate performing anastomoses at the retrocostal segment. After radiotherapy, we believe that retrocostal anastomosis is more suitable. The problematic nature of radiotherapy was ultimately little discussed by Kim et al. in their article. DOI: 10.1097/PRS.0b013e3182a4c4d0
Benoit Chaput, M.D. Ignacio Garrido, M.D., Ph.D. Jean Pierre Chavoin, M.D. Dimitri Gangloff, M.D. Jean Louis Grolleau, M.D. University Hospital Rangueil Toulouse, France Correspondence to Dr. Chaput University Hospital Rangueil 1 Avenue Jean Poulhès 31059 Toulouse, France [email protected]
disclosure The authors have no financial interest to declare in relation to the content of this article. REFERENCES 1. Kim H, Lim SY, Pyon JK, et al. Rib-sparing and internal mammary artery-preserving microsurgical breast reconstruc-
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tion with the free DIEP flap. Plast Reconstr Surg. 2013;131: 327e–334e. 2. Leclère FM, Mordon S, Ramboaniaina S, Schoofs M. [Breast reconstruction with a free DIEP flap complicated by spontaneous rupture of internal mammary artery]. Ann Chir Plast Esthet. 2010;55:593–596. 3. Munhoz AM, Ishida LH, Montag E, et al. Perforator flap breast reconstruction using internal mammary perforator branches as a recipient site: An anatomical and clinical analysis. Plast Reconstr Surg. 2004;114:62–68. 4. Saint-Cyr M, Chang DW, Robb GL, Chevray PM. Internal mammary perforator recipient vessels for breast reconstruction using free TRAM, DIEP, and SIEA flaps. Plast Reconstr Surg. 2007;120:1769–1773.
Reply: Rib-Sparing and Internal Mammary Artery–Preserving Microsurgical Breast Reconstruction with the Free DIEP Flap Sir :
We greatly appreciate Dr. Chaput et al.’s informative comment on our article “Rib-Sparing and Internal Mammary Artery–Preserving Microsurgical Breast Reconstruction with the Free DIEP Flap,”1 which claims that the rib seems to have a protective effect against radiotherapy on internal mammary vessels. In the literature, Parrett et al.2 also suggested a radioprotective effect from the rib by observing less friable internal mammary vessels below the rib cartilage than the segment within the interspace. Since the histopathological effect of radiation on internal mammary vessels has not been comparatively investigated between the intercostal and retrocostal segments, it would be very interesting to see the result in the upcoming article from Chaput et al. On the other hand, the other articles reporting the rib-sparing approach did not pay special attention to the effect of prior radiation. Darcy et al.3 reported the successful intercostal space approach to the internal mammary vessels in 463 microvascular breast reconstructions, of which 83 percent were delayed reconstruction. Sacks and Chang4 reported 100 flaps with an intercostal space approach, including 25 flaps for delayed reconstruction. Although the exact number of patients was not disclosed in these two studies, they might have included patients who had undergone radiation therapy before reconstruction. In our setting, immediate reconstruction is much more common, and three among 100 cases in our study had received radiation therapy following prior partial or total mastectomy. We could perform the ribsparing intercostal approach in these cases without much difficulty and had the similar experience in more subsequent cases including radionecrosis after that study period (Fig. 1). A little fibrotic change on intercostal muscle and perivascular tissue was seen, but this did not significantly affect the performance of microanastomosis and its outcome. Since the dose and method of delivery of radiation vary among centers, the change of perivascular tissue and vessel would be quite variable. Although the prudent approach to the internal mammary vessel is desired in patients having prior radiation on the chest
Volume 132, Number 5 • Letters
Fig. 1. A 55-year-old woman who had undergone mastectomy and radiotherapy 13 years earlier presented with radionecrosis on her anterior chest wall. The internal mammary vessels were approached using the second intercostal space without rib resection or trimming, and the deep inferior epigastric flap was successfully transferred to the defect.
wall, the rib-sparing technique can still be attempted with a high success rate when the radiation-induced change is not severe. If the significant difficulty of using the intercostal segment is encountered intraoperatively, the rib-sparing approach can be easily converted to a rib resection approach for exploring the retrocostal segment, although we have not yet experienced this situation. A larger-scale outcome study would be warranted to draw a sounder conclusion on the safety of using the intercostal segment of the internal mammary vessel in prior radiation patients. DOI: 10.1097/PRS.0b013e3182a4c536
Hyungsuk Kim, M.D. Goo-Hyun Mun, M.D., Ph.D. Department of Plastic Surgery Samsung Medical Center Sungkyunkwan University School of Medicine Seoul, South Korea Correspondence to Dr. Mun Department of Plastic Surgery Samsung Medical Center Sungkyunkwan University School of Medicine Irwon-dong 50 Gangnam-gu, Seoul, South Korea [email protected]
DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication. REFERENCES 1. Kim H, Lim SY, Pyon JK, et al. Rib-sparing and internal mammary artery–preserving microsurgical breast reconstruc-
tion with the free DIEP flap. Plast Reconstr Surg. 2013;131: 327e–334e. 2. Parrett BM, Caterson SA, Tobias AM, Lee BT. The rib-sparing technique for internal mammary vessel exposure in microsurgical breast reconstruction. Ann Plast Surg. 2008;60: 241–243. 3. Darcy CM, Smit JM, Audolfsson T, Acosta R. Surgical technique: The intercostal space approach to the internal mammary vessels in 463 microvascular breast reconstructions. J Plast Reconstr Aesthet Surg. 2011;64:58–62. 4. Sacks JM, Chang DW. Rib-sparing internal mammary vessel harvest for microvascular breast reconstruction in 100 consecutive cases. Plast Reconstr Surg. 2009;123:1403–1407.
Scarpa Fascia Preservation during Abdominoplasty: Randomized Clinical Study of Efficacy and Safety Sir:
C
osta-Ferreira et al. report the findings of their level I study and conclude that preservation of the Scarpa fascia significantly reduces the incidence of seromas after abdominoplasty.1 Patients were randomized, with 80 patients in each group. These authors report a seroma rate of 18.8 percent among control patients and 2.5 percent for the study group. Among measured parameters, there were no other significant differences between groups. It would seem the authors’ conclusions, which confirm their a priori hypothesis,2 are undeniable. Or are they? This article was of great interest to me because I perform essentially a traditional abdominoplasty, with simultaneous liposuction of the epigastrium and flanks in most cases (the authors treat the flanks only). My seroma rate is 5.4 percent—only marginally higher than the rate reported by these investigators—yet I do
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Benoit Chaput, M.D. Ignacio Garrido, M.D., Ph.D. Jean Pierre Chavoin, M.D. Dimitri Gangloff, M.D. Jean Louis Grolleau, M.D. University Hospital Rangueil Toulouse, France Correspondence to Dr. Chaput University Hospital Rangueil 1 Avenue Jean Poulhès 31059 Toulouse, France [email protected]
disclosure The authors have no financial interest to declare in relation to the content of this article. REFERENCES 1. Kim H, Lim SY, Pyon JK, et al. Rib-sparing and internal mammary artery-preserving microsurgical breast reconstruc-
870e
tion with the free DIEP flap. Plast Reconstr Surg. 2013;131: 327e–334e. 2. Leclère FM, Mordon S, Ramboaniaina S, Schoofs M. [Breast reconstruction with a free DIEP flap complicated by spontaneous rupture of internal mammary artery]. Ann Chir Plast Esthet. 2010;55:593–596. 3. Munhoz AM, Ishida LH, Montag E, et al. Perforator flap breast reconstruction using internal mammary perforator branches as a recipient site: An anatomical and clinical analysis. Plast Reconstr Surg. 2004;114:62–68. 4. Saint-Cyr M, Chang DW, Robb GL, Chevray PM. Internal mammary perforator recipient vessels for breast reconstruction using free TRAM, DIEP, and SIEA flaps. Plast Reconstr Surg. 2007;120:1769–1773.
Reply: Rib-Sparing and Internal Mammary Artery–Preserving Microsurgical Breast Reconstruction with the Free DIEP Flap Sir :
We greatly appreciate Dr. Chaput et al.’s informative comment on our article “Rib-Sparing and Internal Mammary Artery–Preserving Microsurgical Breast Reconstruction with the Free DIEP Flap,”1 which claims that the rib seems to have a protective effect against radiotherapy on internal mammary vessels. In the literature, Parrett et al.2 also suggested a radioprotective effect from the rib by observing less friable internal mammary vessels below the rib cartilage than the segment within the interspace. Since the histopathological effect of radiation on internal mammary vessels has not been comparatively investigated between the intercostal and retrocostal segments, it would be very interesting to see the result in the upcoming article from Chaput et al. On the other hand, the other articles reporting the rib-sparing approach did not pay special attention to the effect of prior radiation. Darcy et al.3 reported the successful intercostal space approach to the internal mammary vessels in 463 microvascular breast reconstructions, of which 83 percent were delayed reconstruction. Sacks and Chang4 reported 100 flaps with an intercostal space approach, including 25 flaps for delayed reconstruction. Although the exact number of patients was not disclosed in these two studies, they might have included patients who had undergone radiation therapy before reconstruction. In our setting, immediate reconstruction is much more common, and three among 100 cases in our study had received radiation therapy following prior partial or total mastectomy. We could perform the ribsparing intercostal approach in these cases without much difficulty and had the similar experience in more subsequent cases including radionecrosis after that study period (Fig. 1). A little fibrotic change on intercostal muscle and perivascular tissue was seen, but this did not significantly affect the performance of microanastomosis and its outcome. Since the dose and method of delivery of radiation vary among centers, the change of perivascular tissue and vessel would be quite variable. Although the prudent approach to the internal mammary vessel is desired in patients having prior radiation on the chest
Volume 132, Number 5 • Letters
Fig. 1. A 55-year-old woman who had undergone mastectomy and radiotherapy 13 years earlier presented with radionecrosis on her anterior chest wall. The internal mammary vessels were approached using the second intercostal space without rib resection or trimming, and the deep inferior epigastric flap was successfully transferred to the defect.
wall, the rib-sparing technique can still be attempted with a high success rate when the radiation-induced change is not severe. If the significant difficulty of using the intercostal segment is encountered intraoperatively, the rib-sparing approach can be easily converted to a rib resection approach for exploring the retrocostal segment, although we have not yet experienced this situation. A larger-scale outcome study would be warranted to draw a sounder conclusion on the safety of using the intercostal segment of the internal mammary vessel in prior radiation patients. DOI: 10.1097/PRS.0b013e3182a4c536
Hyungsuk Kim, M.D. Goo-Hyun Mun, M.D., Ph.D. Department of Plastic Surgery Samsung Medical Center Sungkyunkwan University School of Medicine Seoul, South Korea Correspondence to Dr. Mun Department of Plastic Surgery Samsung Medical Center Sungkyunkwan University School of Medicine Irwon-dong 50 Gangnam-gu, Seoul, South Korea [email protected]
DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication. REFERENCES 1. Kim H, Lim SY, Pyon JK, et al. Rib-sparing and internal mammary artery–preserving microsurgical breast reconstruc-
tion with the free DIEP flap. Plast Reconstr Surg. 2013;131: 327e–334e. 2. Parrett BM, Caterson SA, Tobias AM, Lee BT. The rib-sparing technique for internal mammary vessel exposure in microsurgical breast reconstruction. Ann Plast Surg. 2008;60: 241–243. 3. Darcy CM, Smit JM, Audolfsson T, Acosta R. Surgical technique: The intercostal space approach to the internal mammary vessels in 463 microvascular breast reconstructions. J Plast Reconstr Aesthet Surg. 2011;64:58–62. 4. Sacks JM, Chang DW. Rib-sparing internal mammary vessel harvest for microvascular breast reconstruction in 100 consecutive cases. Plast Reconstr Surg. 2009;123:1403–1407.
Scarpa Fascia Preservation during Abdominoplasty: Randomized Clinical Study of Efficacy and Safety Sir:
C
osta-Ferreira et al. report the findings of their level I study and conclude that preservation of the Scarpa fascia significantly reduces the incidence of seromas after abdominoplasty.1 Patients were randomized, with 80 patients in each group. These authors report a seroma rate of 18.8 percent among control patients and 2.5 percent for the study group. Among measured parameters, there were no other significant differences between groups. It would seem the authors’ conclusions, which confirm their a priori hypothesis,2 are undeniable. Or are they? This article was of great interest to me because I perform essentially a traditional abdominoplasty, with simultaneous liposuction of the epigastrium and flanks in most cases (the authors treat the flanks only). My seroma rate is 5.4 percent—only marginally higher than the rate reported by these investigators—yet I do
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