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Double-Pedicled Abdominal Free Flap Using an Entirely New Microvascular Combination of DIEP and SIEA Vascular Pedicles for Unilateral Breast Reconstruction

2012; Lippincott Williams & Wilkins; Volume: 130; Issue: 5 Linguagem: Inglês

10.1097/prs.0b013e318267d995

1529-4242

Nicholas G Rabey, Ertan Erel, Charles M. Malata,

Breast Implant and Reconstruction

Sir:FigureThe unipedicled deep inferior epigastric perforator (DIEP) flap is the criterion standard technique for postmastectomy autologous tissue breast reconstruction.1,2 However, a single-pedicle arrangement may not provide enough tissue in patients who are slim or have midline abdominal scars. Bipedicled free flap designs increase the usable volume of lower abdominal tissue. Hamdi et al. have eloquently outlined several vascular pedicle combinations for this purpose.3 Our report describes a bipedicled flap construct neither previously reported by others nor included in Hamdi et al.'s otherwise comprehensive classification. A 38-year-old massive weight loss patient presented for immediate breast reconstruction during her neoadjuvant chemotherapy. She had lost 70 kg, leaving thinned subcutaneous fat that limited the available abdominal tissue for unipedicle free flap reconstruction. Despite her appendicectomy and cesarian section scars, she declined implant-based reconstruction on account of planned radiotherapy and personal preference. In addition, previous thigh lifts precluded inferior gluteal perforator and transverse myocutaneous gracilis flap reconstruction. At reconstruction 4 weeks after chemotherapy, the entire infraumbilical lower abdominal flap was raised on a contralateral DIEP vascular pedicle and the ipsilateral superficial inferior epigastric artery (SIEA) flap vessels. In the first step, the DIEP vessels were anastomosed end-to-end to the internal mammary vessels. In the second step, the opposite superficial inferior epigastric vessels were anastomosed to the superior continuation of the deep inferior epigastric vessels cranial to the origin of the perforators (Fig. 1). The patient had an uneventful postoperative recovery and was satisfied with the aesthetic outcome of the procedure.Fig. 1: Intraoperative photograph with an artist's illustration showing bipedicled flap anastomoses including deep inferior epigastric pedicle to the internal mammary (IMA) vessels and superficial inferior epigastric vessels (SIEV) to superior continuity (SC) of deep inferior epigastric vessels. P, Deep inferior epigastric perforator. Arrows on the photograph show the position of anastomoses.In Hamdi et al.'s classification of double-pedicled perforator free flaps, there is no description of the vascular permutation we successfully used (Fig. 2).3 Their type 2 design, with the SIEA vessels anastomosed to the inferior continuation of the deep inferior epigastric vessels, has a similar vessel combination. However, we successfully anastomosed SIEA vessels to the superior continuation of the deep inferior epigastric vessels, the so-called superior continuity arrangement. We propose that this constitutes a type IIb bipedicle flap design and have renamed the original arrangement as type IIa.Fig. 2: Modified Hamdi et al. classification of bipedicled free flap designs. Type I, SIEA/SIEA; type IIa, SIEA/inferior continuity DIEA; type IIb, SIEA/superior continuity DIEA; type IIIa, DIEA/inferior continuity DIE; type IIIb, DIE/superior continuity DIEA; type IV, DIEA/perforator. DIEA, deep inferior epigastric artery; DIE, deep inferior epigastric.Use of the SIEA vessels is beneficial to the patient in several ways; namely, simpler chest wall anastomoses (Fig. 1), reduced flap harvest time, easier flap insetting, and lower morbidity because of total muscle preservation (Table 1). SIEA vessel flap harvest is easier in post–massive weight loss patients, as they have large-caliber SIEA vessels for a given tissue volume.4 As bariatric surgical procedures increase, the number of post–massive weight loss patients presenting for breast reconstruction is also likely to increase.4,5Table 1: Advantages of the SIEA Pedicle Anastomosis to the Superior Continuity of the DIEP Flap Vascular PedicleThis new vascular arrangement adds a further option to the bipedicle free flap designs available for autologous breast reconstruction. The only disadvantage is that the superior continuity of the deep inferior epigastric vessels may sometimes be anatomically too small to allow anastomosis with another vascular pedicle. However, it should be considered in designing bipedicled abdominal free flaps for patients who have undergone not only massive weight loss but also previous abdominal surgery or slim patients in general. Nicholas G. Rabey, M.R.C.S.(Eng.) Ertan Erel, F.R.C.S.(Plast.) Charles M. Malata, F.R.C.S.Plast. Department of Plastic and Reconstructive Surgery Addenbrooke's University Hospital Cambridge University Hospitals NHS Foundation Trust Cambridge, United Kingdom ACKNOWLEDGMENTS The authors thank Louise Stubbings and Graham Newton of the Media Studio at Cambridge University Hospitals NHS Trust for kind assistance with the illustrations in this report. DISCLOSURE The authors have no financial interest to declare in relation to the content of this article.