Plastic and Reconstructive Surgery • November 2013 percent of the time as a true foramen compared with 18 percent of the time in our study.” However, this would not make sense in this portion of the Discussion as this was a paragraph expounding on Miller et al.’s data concerning the exit of the supraorbital nerve. We thank Dr. Hwang for pointing out this error in our editing. Concerning Dr. Hwang’s request for a supratrochlear foramen (or frontal foramen) containing a supratrochlear nerve, the reader can see that Figure 5, below panel, of our article demonstrates a supratrochlear nerve coming out of a frontal or supratrochlear foramen. We have included three more examples of a true foramen as Figures 1 through 3. We reiterate our appreciation to Dr. Hwang for his interest in our article. Fig. 2. The supratrochlear nerve is shown exiting through a true foramen in another specimen.
to 21.5 mm. Our data are not as variable as Andersen et al.’s, and we did not find any supratrochlear branches this far medial, but we cannot explain why. Perhaps part of the explanation is that Andersen's group was measuring at a slightly more caudal point, at the supraorbital rim, whereas we were measuring at the entrance to the corrugator. However, it is highly doubtful that the nerve jumps 4 mm in this very short distance. Finally, in their study, Andersen et al. never seemed to have found a frontal notch or foramen, and felt that the supratrochlear nerve simply entered the forehead at the superomedial aspect of the orbit. We only found this to be the case in about 6 percent of our dissections. Hwang pointed out that in our discussion of the article by Miller et al. we took our frontal/supratrochlear notch/foramen data and accidentally put it into our discussion of the supraorbital notch/foramen. There is more detailed information in our Results section, but this was written in error when writing the Discussion. The sentence the writer is referring to would appropriately read as follows: “…the frontal/ supratrochlear foramen was found to be present only 2
DOI: 10.1097/PRS.0b013e3182a4c2ab
Daniel A. Hatef, M.D. Michael E. De Bakey
Department of Surgery Division of Plastic Surgery Baylor College of Medicine Houston, Texas
Jeffrey E. Janis, M.D. Department of Plastic Surgery Ohio State University Wexner Medical Center Columbus, Ohio Correspondence to Dr. Janis Department of Plastic Surgery Ohio State University Wexner Medical Center 915 Olentangy River Road Suite 2100, Room 2114 Columbus, Ohio 43212 [email protected]
DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication. REFERENCES 1. Janis JE, Hatef DA, Hagan R, et al. Anatomy of the supratrochlear nerve: Implications for the surgical treatment of migraine headaches. Plast Reconstr Surg. 2013;131:743–750. 2. Andersen NB, Bovim G, Sjaastad O. The frontotemporal peripheral nerves: Topographic variations of the supraorbital, supratrochlear and auriculotemporal nerves and their possible clinical significance. Surg Radiol Anat. 2001;23:97–104.
Rib-Sparing and Internal Mammary Artery– Preserving Microsurgical Breast Reconstruction with the Free DIEP Flap Sir:
W
Fig. 3. The supratrochlear nerve is shown exiting through a true foramen in a third specimen.
868e
e read with interest the article entitled “Rib-Sparing and Internal Mammary Artery-Preserving Microsurgical Breast Reconstruction with the Free DIEP Flap” by Kim et al.1 We congratulate the authors on their surgical prowess, and we would like to provide some clarification.
Volume 132, Number 5 • Letters
Fig. 1. Intercostal and retrocostal segments of the internal mammary vessels.
We are currently conducting a prospective and comparative study on histological analysis of internal mammary vessels after radiotherapy prior to microsurgery. We performed a histologic comparison of intercostal and retrocostal segments of internal mammary vessels. In our practice, the deep inferior epigastric perforator flap reconstructions are most often performed
away from the initial cancer treatment, almost always after radiotherapy. So, after radiotherapy, we may find ourselves in difficult situations, with poor-quality vessels that tear during handling and episodes of thrombosis despite anastomoses that are technically well executed.2 Sometimes, internal mammary vessels are so narrow that we decide not to perform the anastomoses and we fall back on the axillary vessels.
Fig. 2. Histologic analysis of the intercostal and retrocostal artery segments after radiotherapy. We can observe an important difference of integrity between the two segments. The retrocostal segment is better preserved.
869e
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-
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
to 21.5 mm. Our data are not as variable as Andersen et al.’s, and we did not find any supratrochlear branches this far medial, but we cannot explain why. Perhaps part of the explanation is that Andersen's group was measuring at a slightly more caudal point, at the supraorbital rim, whereas we were measuring at the entrance to the corrugator. However, it is highly doubtful that the nerve jumps 4 mm in this very short distance. Finally, in their study, Andersen et al. never seemed to have found a frontal notch or foramen, and felt that the supratrochlear nerve simply entered the forehead at the superomedial aspect of the orbit. We only found this to be the case in about 6 percent of our dissections. Hwang pointed out that in our discussion of the article by Miller et al. we took our frontal/supratrochlear notch/foramen data and accidentally put it into our discussion of the supraorbital notch/foramen. There is more detailed information in our Results section, but this was written in error when writing the Discussion. The sentence the writer is referring to would appropriately read as follows: “…the frontal/ supratrochlear foramen was found to be present only 2
DOI: 10.1097/PRS.0b013e3182a4c2ab
Daniel A. Hatef, M.D. Michael E. De Bakey
Department of Surgery Division of Plastic Surgery Baylor College of Medicine Houston, Texas
Jeffrey E. Janis, M.D. Department of Plastic Surgery Ohio State University Wexner Medical Center Columbus, Ohio Correspondence to Dr. Janis Department of Plastic Surgery Ohio State University Wexner Medical Center 915 Olentangy River Road Suite 2100, Room 2114 Columbus, Ohio 43212 [email protected]
DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication. REFERENCES 1. Janis JE, Hatef DA, Hagan R, et al. Anatomy of the supratrochlear nerve: Implications for the surgical treatment of migraine headaches. Plast Reconstr Surg. 2013;131:743–750. 2. Andersen NB, Bovim G, Sjaastad O. The frontotemporal peripheral nerves: Topographic variations of the supraorbital, supratrochlear and auriculotemporal nerves and their possible clinical significance. Surg Radiol Anat. 2001;23:97–104.
Rib-Sparing and Internal Mammary Artery– Preserving Microsurgical Breast Reconstruction with the Free DIEP Flap Sir:
W
Fig. 3. The supratrochlear nerve is shown exiting through a true foramen in a third specimen.
868e
e read with interest the article entitled “Rib-Sparing and Internal Mammary Artery-Preserving Microsurgical Breast Reconstruction with the Free DIEP Flap” by Kim et al.1 We congratulate the authors on their surgical prowess, and we would like to provide some clarification.
Volume 132, Number 5 • Letters
Fig. 1. Intercostal and retrocostal segments of the internal mammary vessels.
We are currently conducting a prospective and comparative study on histological analysis of internal mammary vessels after radiotherapy prior to microsurgery. We performed a histologic comparison of intercostal and retrocostal segments of internal mammary vessels. In our practice, the deep inferior epigastric perforator flap reconstructions are most often performed
away from the initial cancer treatment, almost always after radiotherapy. So, after radiotherapy, we may find ourselves in difficult situations, with poor-quality vessels that tear during handling and episodes of thrombosis despite anastomoses that are technically well executed.2 Sometimes, internal mammary vessels are so narrow that we decide not to perform the anastomoses and we fall back on the axillary vessels.
Fig. 2. Histologic analysis of the intercostal and retrocostal artery segments after radiotherapy. We can observe an important difference of integrity between the two segments. The retrocostal segment is better preserved.
869e
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-
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
