Journal of Plastic, Reconstructive & Aesthetic Surgery (2014) 67, 456e460
The use of the serratus anterior muscle vascular pedicle as recipient site in DIEP flap transfer for breast reconstruction Fabio Santanelli di Pompeo*, Benedetto Longo, Rosaria Laporta, Marco Pagnoni, Enrico Cavalieri Plastic Surgery Unit ‘Sant’Andrea Hospital, School of Medicine and Psychology, “Sapienza” University of Rome, Rome, Italy Received 20 August 2013; accepted 21 December 2013
KEYWORDS Diep flap; Breast reconstruction; Recipient vessels; Serratus anterior vascular pedicle
Summary Currently, the choice for recipient vessels in microvascular breast reconstruction is made between axillary and internal mammary regions. The authors report their experience with anastomosis to a new, unconventional, axillary recipient vessel, the serratus anterior muscle vascular pedicle. Among 340 deep inferior epigastric perforator (DIEP) flap breast reconstructions performed between 2004 and 2013, 11 were successfully revascularised to the serratus anterior (SA) pedicle: In three cases, complications led to a salvage procedure, while in eight cases, anastomosis to this recipient site was electively planned. The pedicle was constantly present, with calibre always comparable to that of flap’s pedicle. At the mean 24-month follow-up, no recipient site complications were observed. The SA muscle pedicle resulted as a reliable choice in salvage procedures and a suitable option for recipient vessel selection in elective cases. ª 2013 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
The achievement of a natural-like breast mound with optimal patient satisfaction and durable aesthetic results with spontaneous sensibility recovery,1 coupled with the chance to retain abdominal wall integrity and function, make deep inferior epigastric perforator (DIEP) flap the
* Corresponding author. Azienda Ospedaliera Sant’Andrea e U.O.D. Chirurgia Plastica, Via di Grottarossa 1035-1039, 00189 Rome, Italy. Tel.: þ39 06 33775692; fax: þ39 06 33776691. E-mail address: [email protected] (F. Santanelli di Pompeo).
gold standard for breast reconstruction. Despite the large consensus over this technique, the choice of performing microanastomosis to axillary or internal mammary regions still remains controversial.2e4 Holmstro ¨m, in 1979, first introduced the subscapular (SS) artery and vein as recipient vessels,5 which has been set aside following Harashina’s report on internal mammary (IM) vessels, which became the primary choice.6 Axillary region regained popularity in 1999 when Lantieri suggested the use of the circumflex scapular (CS) pedicle.7 Recently, the use of microanastomosis to perforators from the internal mammary perforator (IMP) artery and vein has been added as a new choice for
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.2013.12.033
Serratus anterior muscle vascular pedicle
457
recipient vessels,8 although yet not finding large consensus because of their inherent limitations.9,10 While their use may further reduce morbidity to donor site, limiting the dissection of the epigastric pedicle through the rectus muscle, and to recipient site, avoiding removal of costal cartilage, it undoubtedly forces the surgeon to perform a demanding anastomosis on short as well as small vessels, increasing the risk of complications.9e12 The authors report their experience in the use of the serratus anterior (SA) muscle’s vascular pedicle as a new choice for recipient vessel in DIEP flap transfer for breast reconstruction, analysing pro and cons of this site.
Material and methods Between May 2004 and June 2013, 340 breast reconstructions with DIEP flap were performed; among these, 11 patients, who were scheduled for unilateral breast reconstruction, had vascular anastomoses performed to the SA branches. In three cases, complications in DIEP flap transfer to the SA pedicle, which was first used as recipient site, led to a salvage procedure. Case 1: A case involving a 46-year-old patient, showing a vein drainage insufficiency on second postoperative day, was re-explored, and a partially organised haematoma causing compression of pedicle veins compression was found. While removing it, the perforator was accidentally hooked on to the finger and torn off from the deep inferior epigastric pedicle. Vessels were shortened to remove intimal damage at their margins and anastomosed to SA artery and vein branches, so as to obtain a tension-free suture. Case 2: A 53-year-old patient, with a scar from a previous laparoscopic procedure, showed during dissection an interruption of the DIEP pedicle 2 cm distal to the perforator origin. As the DIEP pedicle was too short to reach the CS vessels, the SA pedicle was dissected long enough to reach the severed DIEP vessels and at the level of a coherent calibre.
Table 1 Patients 1-S 2-S 3-S 4-E 5-E 6-E 7-E 8-E 9-E 10-E 11-E a
Case 3: In a 39-year-old patient, a DIEP flap was raised on a single perforator from the lateral row, the vascular pedicle was completely dissected, but accidentally a side perforator was caught in a crossing motor nerve branch by a microvascular clip. When the flap was withdrawn, following deep inferior epigastric vessel section, the pedicle was torn off at the junction to the perforator vessels, and SA branches were used as recipients so as to use single anastomosis for flap perfusion. Subsequently, in the following eight cases (one delayed, seven immediate) anastomosis to the SA recipient site was electively planned, six flaps were raised on a single perforator (four medial and two lateral) and two flaps on two lateral perforators, in which the pedicle was dissected until the confluence of the most distal perforator to the main pedicle. Patients’ and operative data are provided in Table 1.
Results Among 11 DIEP flaps anastomosed to the SA pedicle, the mean overall operative time was 4 h 15 min (Table 1); no vascular complications, nor haematomas or seromas occurred during postoperative course. All flaps healed uneventfully except one, which developed partial skin flap necrosis, which was resolved in outpatient care treatment. Vascular pedicle to SA muscle was constantly present and the calibre was always competent to that of flap’s pedicle. Once distally severed, it was possible to dissect the pedicle sparing the thoracodorsal and long thoracic nerves avoiding upper-limb functional impairment and the scapula alata defect in all cases (Figure 1).13,14 Following its transposition, SA pedicle was in all cases long enough to reach the flap’s pedicle and to perform a tension-free anastomosis, properly positioning the flap on the thoracic wall (Figures 2 and 3). At the mean 24-month follow-up (range, 10e38) no late complications, local or distant recurrences, bulging or herniation of the abdominal wall and decrease in strength during trunk flexion and rotation, nor SA muscle functional impairment were reported.
Patients and operative data. a
Age
Type of mastectomyb
Timing of reconstruction
Flap size (cm)
46 53 39 53 49 58 67 50 52 71 48
MRM SSM MRM SSM SSM NSM MRM SSM NSM MRM SSM
Immediate Immediate Immediate Immediate Immediate Immediate Delayed Immediate Immediate Immediate Immediate
25 20 19 23 21 19 21 25 20 20 25
16 11 10 13 17 9 14 13 14 10 17
Flap weight (grams)
Perforators number (row)
Overall operative time (minutes)c
Follow-up (months)
720 410 385 460 510 370 480 585 500 385 705
1 1 1 1 1 1 2 1 2 1 1
e 265 275 280 250 220 265 240 255 245 255
38 33 30 26 25 22 20 17 14 13 10
(Lateral) (Lateral) (Lateral) (Medial) (Medial) (Lateral) (Lateral) (Medial) (Lateral) (Lateral) (Medial)
S, Salvage case; E, Elective case. MRM, Modified radical mastectomy; SSM, Skin-sparing mastectomy; NSM, Nipple-sparing mastectomy. c Operative time of the first salvage case was not taken into account as anastomosis to the Serratus Anterior pedicle was performed during re-operation. b
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Figure 1 Intraoperative view of the Serratus Anterior muscle vascular pedicle dissected until its terminal branches. TD: thoracodorsal vascular pedicle; ICBN: intercostobrachial nerve; LTN: long thoracic nerve; SA: serratus anterior vascular pedicle; SA-tb: terminal branches of the serratus anterior vascular pedicle.
Discussion Long-lasting debates have grown about the choice between axillary and IM vessels as the recipient site for microanastomosis in breast reconstruction. While several authors have emphasised axillary region’s demerits as accessibility, involvement in oncological breast surgery and radiation therapy, too lateral positioning of the flap, shoulder stiffness and immobilisation and calibre matching, others have underscored the drawbacks of IM region as costal cartilage
Figure 2
excision with contour defects, continuous respiratory movements during anastomosis, postoperative fatal bleeding in irradiated patients, pain, pneumothorax, usage of potential donor vessels for future lifesaving procedures.2e4,15e17 Microanastomosis to IMPs has recently been introduced to avoid the risk of thoracic deformities and to spare IM vessels from future cardiac surgery, but also for the chance to further reduce DIEP flap donor-site morbidity, limiting dissection of the pedicle through the rectus muscle.8e12,18e20 Nevertheless, it yields important drawbacks as IMPs are often not available in delayed reconstructions, which were previously damaged during mastectomy or by radiotherapy.8e11,19,20 Perforator size could also be very small, carrying a higher risk of perfusionrelated complications, forcing the surgeon to change the initial choice from IMPs as recipient vessels to a more conventional anastomosis to IM vessels or to the axillary system, losing all possible IMPs benefits.18,20 Our experience of 87% immediate reconstructions with already dissected axillary vessels, with a high number of skin-sparing mastectomies, together with the aim of avoiding perfusion-related complications21 and IM vessels drawbacks, led us to reconsider axillary region as the ideal site for microvascular anastomoses. We could appreciate the presence of a wide selection of consistent, reliable and safe vessels, promptly accessible due to simultaneous axillary lymphadenectomy, easily and superficially available through a short access in the mid-axillary line, with the absence of vertical respiratory movements and transitory loss of focalisation.16,17 Hence, to overcome the demerits of IMPs, while keeping the indisputable potential advantage of reduced dissection through the rectus abdominis muscle with limited anterior sheath incision, terminal branches of the SA pedicle were selected as recipient vessels for microvascular anastomoses. Dissection was performed distally until a good calibre match with flap’s perforator was achieved, and proximally until the range of pedicle movement was sufficient to reach flap perforator to perform tension-free anastomosis with correct flap positioning on the chest wall. In a similar manner, the dissection of flap’s pedicle was carried out until the vessel size was deemed appropriate and matched
Preoperative and postoperative picture of the first salvage case.
Serratus anterior muscle vascular pedicle
Figure 3
459
Preoperative and postoperative picture of the elective delayed case.
that of the selected recipient SA branch. In this way, the amount of rectus muscle being dissected for DIEP pedicle harvest can be consistently reduced, with shorter fascial incision and limited or null transection of its segmental innervation, hence possibly minimising donor-site morbidity.22e24 The need to dissect the recipient SA vessels did not affect the length of the operation as in immediate reconstructions after axillary lymph nodes dissection, the SS and thoracodorsal pedicles are already exposed, hence locating and dissecting the SA pedicle turn out to be neither difficult nor lengthy. Moreover, in our experience, recipient vessels in delayed cases are prepared simultaneously with harvest flaps and the operative time required does not influence the overall length of the operation. Despite the limited calibre of the pedicle, fat necrosis was not observed in any of the cases. Just in one case, superficial skin flap necrosis occurred, but spontaneously resolved in outpatient care. Perfusion-related complications might be correlated to several factors as smoking, nulliparity, type and number of perforators and flap’s angiosomes21; however, the recipient vessels used for anastomosis do not seem to have a direct correlation with flap necrosis. As reported by other authors, blood supply in a free flap does not depend on the flow rate of recipient vessels before anastomosis, but is related to the flap size.25e27 Larger flaps will have higher flow rates, thereby needing higher drainage capability. To reduce the risk of venous congestion, flap drainage can be increased by adding veins in parallel and choosing larger diameter veins.27 Therefore, careful evaluation of patients, accurate preoperative planning of the flap and administration of combined intravenous crystalloid/colloid infusion therapy, together with the chance to perform a second vein anastomosis, can be effective in reducing flap’s ischaemic complications.21 Indications for the use of the SA pedicle are not different to those for the use of conventional axillary vessels. However, donor-site morbidity reduction obtained with the limited dissection through the rectus abdominis muscle results in a short pedicle, inadequate to reach the conventional vessels in the axilla; in such cases, anastomosis on the terminal branches of the SA pedicle, accurately
dissected and anteriorly rotated, allows for adequate positioning of the flap. Furthermore, their use allows to avoid the drawbacks of anastomosis on IM vessel perforators, even though supermicrosurgical skills are still required due to limited vessels’ calibre. Patient’s discomfort with respect to the arm is somehow comparable to that of patients with anastomosis to conventional axillary vessels. Indeed, even in the use of the SA pedicle, a moderate abduction, although not imperative, is suggested for the first 48e72 h. Such a posture does not affect the length of the pedicle, however, excessive abduction or adduction should be avoided. In our experience of 40 delayed latissimus dorsi (LD) flap breast reconstructions, we found that previous lymphadenectomy did not seem to affect the presence of SA branches; more than one is constantly present with appropriate length and calibre to be used for a tension-free anastomosis and adequate medial insetting of the flap. In addition, the presence of a conspicuous number of potential recipient vessels in the axillary region represents an additional advantage of this site, which, moreover, does not compromise LD muscle vascularisation, sparing its use for further salvage procedures.28
Conclusions Based on our experience and on the ‘minimally invasive’ evolution trend for abdominal flap-harvesting technique, the branches from the SA pedicle should be considered as a reliable choice in salvage procedures and as a suitable alternative option for recipient vessel selection in elective supermicrosurgical breast reconstruction.
Ethical approval Not required.
Funding None.
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Conflicts of interest None declared.
References 1. Santanelli F, Longo B, Angelini M, Laporta R, Paolini G. Prospective computerized analyses of sensibility in breast reconstruction with non-reinnervated DIEP flap. Plast Reconstr Surg 2011;127:1790e5. 2. Yang SJ, Eom JS, Lee TJ, Ahn SH, Son BH. Recipient vessel selection in immediate breast reconstruction with free abdominal tissue transfer after nipple-sparing mastectomy. Arch Plast Surg 2012;39:216e21. 3. Wallace CG, Shokrollahi K. Thoracodorsal or internal mammary recipient vessels for microvascular breast reconstruction? Ann Plast Surg 2012;68:536. 4. Quaba O, Brown A, Stevenson H. Internal mammary vessels, recipient vessels of choice for free tissue breast reconstruction? Br J Plast Surg 2005;58:881e2. 5. Holmstro ¨m H. The free abdominoplasty flap and its use in breast reconstruction: an experimental study and clinical case report. Scand J Plast Reconstr Surg 1979;13:423e7. 6. Harashina T, Imai T, Nakajima H, Fujino T. Breast reconstruction with microsurgical free composite tissue transplantation. Br J Plast Surg 1980;33:30e7. 7. Lantieri LA, Mitrofanoff M, Rimareix F, Gaston E, Raulo Y, Baruch J. Use of circumflex scapular vessels as a recipient pedicle for autologous breast reconstruction: a report of 40 consecutive cases. Plast Reconstr Surg 1999;104:2049e53. 8. Guzzetti T, Thione A. Successful breast reconstruction with a perforator to deep inferior epigastric perforator flap. Ann Plast Surg 2001;46:641e3. 9. 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;114:62e8. 10. Munhoz AM. Internal mammary perforator recipient vessels for breast reconstruction using free TRAM, DIEP, and SIEA flaps. Plast Reconstr Surg 2008;122:315e6. 11. Hamdi M, Blondeel P, Van Landuyt K, Monstrey S. Algorithm in choosing recipient vessels for perforator free flap in breast reconstruction: the role of the internal mammary perforators. Br J Plast Surg 2004;57:258e65. 12. 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;120:1769e73. 13. Godat DM, Sanger JR, Lifchez SD, et al. Detailed neurovascular anatomy of the serratus anterior muscle: implications for a functional muscle flap with multiple independent force vectors. Plast Reconstr Surg 2004;114:21e8. 14. Paolini G, Amoroso M, Pugliese P, Longo B, Santanelli F. Functional sequelae following bilateral mastectomy and
15.
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24.
25.
26.
27.
28.
immediate reconstruction with latissimus dorsi flap: mediumterm follow-up. J Plast Surg Hand Surg 2013 [Epub ahead of print]. Nahabedian M. The internal mammary artery and vein as recipient vessels for microvascular breast reconstruction. Ann Plast Surg 2012;68:537e8. Guay NA. The thoracodorsal vessels are advantageous, reliable, and safe recipient vessels for free abdominal flap breast reconstruction. Ann Plast Surg 2012;68:539e41. Banwell M, Trotter D, Ramakrishnan V. The thoracodorsal artery and vein as recipient vessels for microsurgical breast reconstruction. Ann Plast Surg 2012;68:542e3. Follmar KE, Prucz RB, Manahan MA, Magarakis M, Rad AN, Rosson GD. Internal mammary intercostal perforators instead of the true internal mammary vessels as the recipient vessels for breast reconstruction. Plast Reconstr Surg 2011;127: 34e40. Haywood RM, Raurell A, Perks AG, Sasson EM, Logan AM, Phillips J. Autologous free tissue breast reconstruction using the internal mammary perforators as recipient vessels. Br J Plast Surg 2003;56:689e91. Park MC, Lee JH, Chung J, Lee SH. Use of internal mammary vessel perforator as a recipient vessel for free tram breast reconstruction. Ann Plast Surg 2003;50:132e7. Santanelli F, Longo B, Cagli B, Pugliese P, Sorotos M, Paolini G. Predictive and protective factors for partial necrosis in diep flap breast reconstruction: does nulliparity bias flap viability? Ann Plast Surg 2013 [Epub ahead of print]. Rozen WM, Ashton MW. The “limited rectus sheath incisions” technique for DIEP flaps using preoperative CT angiography. Microsurgery 2009;29:525e8. Rozen WM, Ashton MW, Kiil BJ, et al. Avoiding denervation of rectus abdominis in DIEP flap harvest II: an intraoperative assessment of the nerves to rectus. Plast Reconstr Surg 2008; 122:1321e5. Nahabedian MY, Dooley W, Singh N, Manson PN. Contour abnormalities of the abdomen after breast reconstruction with abdominal flaps: the role of muscle preservation. Plast Reconstr Surg 2002;109:91e101. Lorenzetti F, Suominen S, Tukiainen E, et al. Evaluation of blood flow in free microvascular flaps. J Reconstr Microsurg 2001;17:163e7. Lorenzetti F, Kuokkanen H, von Smitten K, Asko-Seljavaara S. Intraoperative evaluation of blood flow in the internal mammary or thoracodorsal artery as a recipient vessel for a free TRAM flap. Ann Plast Surg 2001;46:590e3. Rubino C, Ramakrishnan V, Figus A, et al. Flap size/flow rate relationship in perforator flaps and its importance in DIEAP flap drainage. J Plast Reconstr Aesthet Surg 2009;62: 1666e70. Laporta R, Longo B, Pagnoni M, Catta F, Garbarino GM, Santanelli F. Accidental injury of the latissimus dorsi flap pedicle during axillae dissection: types and reconstruction algorithm. Microsurgery 2014;34:5e9.
The use of the serratus anterior muscle vascular pedicle as recipient site in DIEP flap transfer for breast reconstruction Fabio Santanelli di Pompeo*, Benedetto Longo, Rosaria Laporta, Marco Pagnoni, Enrico Cavalieri Plastic Surgery Unit ‘Sant’Andrea Hospital, School of Medicine and Psychology, “Sapienza” University of Rome, Rome, Italy Received 20 August 2013; accepted 21 December 2013
KEYWORDS Diep flap; Breast reconstruction; Recipient vessels; Serratus anterior vascular pedicle
Summary Currently, the choice for recipient vessels in microvascular breast reconstruction is made between axillary and internal mammary regions. The authors report their experience with anastomosis to a new, unconventional, axillary recipient vessel, the serratus anterior muscle vascular pedicle. Among 340 deep inferior epigastric perforator (DIEP) flap breast reconstructions performed between 2004 and 2013, 11 were successfully revascularised to the serratus anterior (SA) pedicle: In three cases, complications led to a salvage procedure, while in eight cases, anastomosis to this recipient site was electively planned. The pedicle was constantly present, with calibre always comparable to that of flap’s pedicle. At the mean 24-month follow-up, no recipient site complications were observed. The SA muscle pedicle resulted as a reliable choice in salvage procedures and a suitable option for recipient vessel selection in elective cases. ª 2013 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
The achievement of a natural-like breast mound with optimal patient satisfaction and durable aesthetic results with spontaneous sensibility recovery,1 coupled with the chance to retain abdominal wall integrity and function, make deep inferior epigastric perforator (DIEP) flap the
* Corresponding author. Azienda Ospedaliera Sant’Andrea e U.O.D. Chirurgia Plastica, Via di Grottarossa 1035-1039, 00189 Rome, Italy. Tel.: þ39 06 33775692; fax: þ39 06 33776691. E-mail address: [email protected] (F. Santanelli di Pompeo).
gold standard for breast reconstruction. Despite the large consensus over this technique, the choice of performing microanastomosis to axillary or internal mammary regions still remains controversial.2e4 Holmstro ¨m, in 1979, first introduced the subscapular (SS) artery and vein as recipient vessels,5 which has been set aside following Harashina’s report on internal mammary (IM) vessels, which became the primary choice.6 Axillary region regained popularity in 1999 when Lantieri suggested the use of the circumflex scapular (CS) pedicle.7 Recently, the use of microanastomosis to perforators from the internal mammary perforator (IMP) artery and vein has been added as a new choice for
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.2013.12.033
Serratus anterior muscle vascular pedicle
457
recipient vessels,8 although yet not finding large consensus because of their inherent limitations.9,10 While their use may further reduce morbidity to donor site, limiting the dissection of the epigastric pedicle through the rectus muscle, and to recipient site, avoiding removal of costal cartilage, it undoubtedly forces the surgeon to perform a demanding anastomosis on short as well as small vessels, increasing the risk of complications.9e12 The authors report their experience in the use of the serratus anterior (SA) muscle’s vascular pedicle as a new choice for recipient vessel in DIEP flap transfer for breast reconstruction, analysing pro and cons of this site.
Material and methods Between May 2004 and June 2013, 340 breast reconstructions with DIEP flap were performed; among these, 11 patients, who were scheduled for unilateral breast reconstruction, had vascular anastomoses performed to the SA branches. In three cases, complications in DIEP flap transfer to the SA pedicle, which was first used as recipient site, led to a salvage procedure. Case 1: A case involving a 46-year-old patient, showing a vein drainage insufficiency on second postoperative day, was re-explored, and a partially organised haematoma causing compression of pedicle veins compression was found. While removing it, the perforator was accidentally hooked on to the finger and torn off from the deep inferior epigastric pedicle. Vessels were shortened to remove intimal damage at their margins and anastomosed to SA artery and vein branches, so as to obtain a tension-free suture. Case 2: A 53-year-old patient, with a scar from a previous laparoscopic procedure, showed during dissection an interruption of the DIEP pedicle 2 cm distal to the perforator origin. As the DIEP pedicle was too short to reach the CS vessels, the SA pedicle was dissected long enough to reach the severed DIEP vessels and at the level of a coherent calibre.
Table 1 Patients 1-S 2-S 3-S 4-E 5-E 6-E 7-E 8-E 9-E 10-E 11-E a
Case 3: In a 39-year-old patient, a DIEP flap was raised on a single perforator from the lateral row, the vascular pedicle was completely dissected, but accidentally a side perforator was caught in a crossing motor nerve branch by a microvascular clip. When the flap was withdrawn, following deep inferior epigastric vessel section, the pedicle was torn off at the junction to the perforator vessels, and SA branches were used as recipients so as to use single anastomosis for flap perfusion. Subsequently, in the following eight cases (one delayed, seven immediate) anastomosis to the SA recipient site was electively planned, six flaps were raised on a single perforator (four medial and two lateral) and two flaps on two lateral perforators, in which the pedicle was dissected until the confluence of the most distal perforator to the main pedicle. Patients’ and operative data are provided in Table 1.
Results Among 11 DIEP flaps anastomosed to the SA pedicle, the mean overall operative time was 4 h 15 min (Table 1); no vascular complications, nor haematomas or seromas occurred during postoperative course. All flaps healed uneventfully except one, which developed partial skin flap necrosis, which was resolved in outpatient care treatment. Vascular pedicle to SA muscle was constantly present and the calibre was always competent to that of flap’s pedicle. Once distally severed, it was possible to dissect the pedicle sparing the thoracodorsal and long thoracic nerves avoiding upper-limb functional impairment and the scapula alata defect in all cases (Figure 1).13,14 Following its transposition, SA pedicle was in all cases long enough to reach the flap’s pedicle and to perform a tension-free anastomosis, properly positioning the flap on the thoracic wall (Figures 2 and 3). At the mean 24-month follow-up (range, 10e38) no late complications, local or distant recurrences, bulging or herniation of the abdominal wall and decrease in strength during trunk flexion and rotation, nor SA muscle functional impairment were reported.
Patients and operative data. a
Age
Type of mastectomyb
Timing of reconstruction
Flap size (cm)
46 53 39 53 49 58 67 50 52 71 48
MRM SSM MRM SSM SSM NSM MRM SSM NSM MRM SSM
Immediate Immediate Immediate Immediate Immediate Immediate Delayed Immediate Immediate Immediate Immediate
25 20 19 23 21 19 21 25 20 20 25
16 11 10 13 17 9 14 13 14 10 17
Flap weight (grams)
Perforators number (row)
Overall operative time (minutes)c
Follow-up (months)
720 410 385 460 510 370 480 585 500 385 705
1 1 1 1 1 1 2 1 2 1 1
e 265 275 280 250 220 265 240 255 245 255
38 33 30 26 25 22 20 17 14 13 10
(Lateral) (Lateral) (Lateral) (Medial) (Medial) (Lateral) (Lateral) (Medial) (Lateral) (Lateral) (Medial)
S, Salvage case; E, Elective case. MRM, Modified radical mastectomy; SSM, Skin-sparing mastectomy; NSM, Nipple-sparing mastectomy. c Operative time of the first salvage case was not taken into account as anastomosis to the Serratus Anterior pedicle was performed during re-operation. b
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Figure 1 Intraoperative view of the Serratus Anterior muscle vascular pedicle dissected until its terminal branches. TD: thoracodorsal vascular pedicle; ICBN: intercostobrachial nerve; LTN: long thoracic nerve; SA: serratus anterior vascular pedicle; SA-tb: terminal branches of the serratus anterior vascular pedicle.
Discussion Long-lasting debates have grown about the choice between axillary and IM vessels as the recipient site for microanastomosis in breast reconstruction. While several authors have emphasised axillary region’s demerits as accessibility, involvement in oncological breast surgery and radiation therapy, too lateral positioning of the flap, shoulder stiffness and immobilisation and calibre matching, others have underscored the drawbacks of IM region as costal cartilage
Figure 2
excision with contour defects, continuous respiratory movements during anastomosis, postoperative fatal bleeding in irradiated patients, pain, pneumothorax, usage of potential donor vessels for future lifesaving procedures.2e4,15e17 Microanastomosis to IMPs has recently been introduced to avoid the risk of thoracic deformities and to spare IM vessels from future cardiac surgery, but also for the chance to further reduce DIEP flap donor-site morbidity, limiting dissection of the pedicle through the rectus muscle.8e12,18e20 Nevertheless, it yields important drawbacks as IMPs are often not available in delayed reconstructions, which were previously damaged during mastectomy or by radiotherapy.8e11,19,20 Perforator size could also be very small, carrying a higher risk of perfusionrelated complications, forcing the surgeon to change the initial choice from IMPs as recipient vessels to a more conventional anastomosis to IM vessels or to the axillary system, losing all possible IMPs benefits.18,20 Our experience of 87% immediate reconstructions with already dissected axillary vessels, with a high number of skin-sparing mastectomies, together with the aim of avoiding perfusion-related complications21 and IM vessels drawbacks, led us to reconsider axillary region as the ideal site for microvascular anastomoses. We could appreciate the presence of a wide selection of consistent, reliable and safe vessels, promptly accessible due to simultaneous axillary lymphadenectomy, easily and superficially available through a short access in the mid-axillary line, with the absence of vertical respiratory movements and transitory loss of focalisation.16,17 Hence, to overcome the demerits of IMPs, while keeping the indisputable potential advantage of reduced dissection through the rectus abdominis muscle with limited anterior sheath incision, terminal branches of the SA pedicle were selected as recipient vessels for microvascular anastomoses. Dissection was performed distally until a good calibre match with flap’s perforator was achieved, and proximally until the range of pedicle movement was sufficient to reach flap perforator to perform tension-free anastomosis with correct flap positioning on the chest wall. In a similar manner, the dissection of flap’s pedicle was carried out until the vessel size was deemed appropriate and matched
Preoperative and postoperative picture of the first salvage case.
Serratus anterior muscle vascular pedicle
Figure 3
459
Preoperative and postoperative picture of the elective delayed case.
that of the selected recipient SA branch. In this way, the amount of rectus muscle being dissected for DIEP pedicle harvest can be consistently reduced, with shorter fascial incision and limited or null transection of its segmental innervation, hence possibly minimising donor-site morbidity.22e24 The need to dissect the recipient SA vessels did not affect the length of the operation as in immediate reconstructions after axillary lymph nodes dissection, the SS and thoracodorsal pedicles are already exposed, hence locating and dissecting the SA pedicle turn out to be neither difficult nor lengthy. Moreover, in our experience, recipient vessels in delayed cases are prepared simultaneously with harvest flaps and the operative time required does not influence the overall length of the operation. Despite the limited calibre of the pedicle, fat necrosis was not observed in any of the cases. Just in one case, superficial skin flap necrosis occurred, but spontaneously resolved in outpatient care. Perfusion-related complications might be correlated to several factors as smoking, nulliparity, type and number of perforators and flap’s angiosomes21; however, the recipient vessels used for anastomosis do not seem to have a direct correlation with flap necrosis. As reported by other authors, blood supply in a free flap does not depend on the flow rate of recipient vessels before anastomosis, but is related to the flap size.25e27 Larger flaps will have higher flow rates, thereby needing higher drainage capability. To reduce the risk of venous congestion, flap drainage can be increased by adding veins in parallel and choosing larger diameter veins.27 Therefore, careful evaluation of patients, accurate preoperative planning of the flap and administration of combined intravenous crystalloid/colloid infusion therapy, together with the chance to perform a second vein anastomosis, can be effective in reducing flap’s ischaemic complications.21 Indications for the use of the SA pedicle are not different to those for the use of conventional axillary vessels. However, donor-site morbidity reduction obtained with the limited dissection through the rectus abdominis muscle results in a short pedicle, inadequate to reach the conventional vessels in the axilla; in such cases, anastomosis on the terminal branches of the SA pedicle, accurately
dissected and anteriorly rotated, allows for adequate positioning of the flap. Furthermore, their use allows to avoid the drawbacks of anastomosis on IM vessel perforators, even though supermicrosurgical skills are still required due to limited vessels’ calibre. Patient’s discomfort with respect to the arm is somehow comparable to that of patients with anastomosis to conventional axillary vessels. Indeed, even in the use of the SA pedicle, a moderate abduction, although not imperative, is suggested for the first 48e72 h. Such a posture does not affect the length of the pedicle, however, excessive abduction or adduction should be avoided. In our experience of 40 delayed latissimus dorsi (LD) flap breast reconstructions, we found that previous lymphadenectomy did not seem to affect the presence of SA branches; more than one is constantly present with appropriate length and calibre to be used for a tension-free anastomosis and adequate medial insetting of the flap. In addition, the presence of a conspicuous number of potential recipient vessels in the axillary region represents an additional advantage of this site, which, moreover, does not compromise LD muscle vascularisation, sparing its use for further salvage procedures.28
Conclusions Based on our experience and on the ‘minimally invasive’ evolution trend for abdominal flap-harvesting technique, the branches from the SA pedicle should be considered as a reliable choice in salvage procedures and as a suitable alternative option for recipient vessel selection in elective supermicrosurgical breast reconstruction.
Ethical approval Not required.
Funding None.
460
F. Santanelli di Pompeo et al.
Conflicts of interest None declared.
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