A CTA Guided Algorithm for Double-pedicle Abdominal Based Breast Reconstruction: Perforator Selection and Anastomosis
Min-Jeong Cho, M.D., Austin Hembd, M.D., Christopher Venutolo, B.S., Nicholas T. Haddock, M.D., Sumeet S. Teotia, M.D..
University of Texas Southwestern Medical Center, Dallas, TX, USA.
Using a hemi-abdominal flap for unilateral breast reconstruction in patients may not be ideal due to paucity of abdominal tissue, presence of a lower abdominal midline scar, or a larger and/or ptotic contralateral native breast. Several algorithms exist to make these flaps successful but all ultimately require an anastomoses sequence. We present our experience with use of imaging to predict flap dominance and anastomosis sequence to make them consistently successful.
75 consecutive bi-pedicled abdominal composite free flaps for unilateral breast reconstruction were performed. Patient demographics, type/weights of flaps, number of anastomoses, location of perforators, length/type of pedicles, and flap related complications were recorded. Guided by CTA imaging, the bi-pedicled flaps were anastomosed to split internal mammary artery/vein (IMA/V) or an intra-flap anastomosis was performed and anastomosed to the IMA/V. Preoperative CTA was obtained to depict the pattern of perforators, flap dominance, and feasibility for intra-flap anastomosis.
75 patients underwent composite DIEP and/or SIEA flaps (150 total flaps). There were 62 DIEP-DIEP flaps, 11 DIEP-SIEA flaps, and 2 SIEA-SIEA flaps. Average flap weight was 1,054 +/- 420 grams (average age 57 yrs and average BMI was 27 +/- 3.9). Sixty-one patients had delayed reconstruction and 14 were immediate. 31 patients had intra-flap anastomosis over the abdomen and carried as single composite flap to cranial IMA/V; 44 patients had independent bi-pedicle flaps anastomosed to cranial and caudal split IMA/V. Flaps were not split in midline, but carried as a composite hemi- abdominal flap with anastomosis to the IMA/V. There were no flap losses.
Guided by preoperative CTA imaging, we recommend the consistent use of these bi-pedicle hemi-abdominal flaps for unilateral reconstruction, primarily those with delayed reconstruction and radiation deficits. Preoperative CTA imaging is crucial in directing perforator dissection to maximize perfusion zones and guide in performing intra-flap anastomosis over the abdomen. All patients with intra-flap anastomosis had preoperative CTA criteria for success. Technical considerations such as flap inset and folding, use of simplified algorithm, perforator selection and need for intra-flap anastomosis will be presented to make these flaps consistently successful.
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