DOI: 10.1097/01.prs.0000207386.02262.bf
,
,
PMID: 16641706
Issn Print: 0032-1052
Publication Date: 2006/04/15
Facebook
Twitter
LinkedIn
Email
 |
Checking for direct PDF access through Ovid | |
Excerpt
Pedicled transverse rectus abdominis musculocutaneous (TRAM) flaps, though limited by their abdominal attachment, have enjoyed a stable connection between pedicle and skin flap. Pedicle vessels and perforators are well supported by surrounding muscle and fascial attachments. Once the TRAM is passed to the chest and the muscle secured to the chest wall in appropriate orientation, the skin and fat component can be tailored and inset easily, with the flap well supported.6
With the advent of free TRAM flaps, including the muscle-sparing free TRAM flap, there was new freedom in positioning tissues in whatever orientation appropriate, without an abdominal tether. The flap tissues could still be secured by suturing the muscle and fascia harvested with the flap directly to the chest wall. This ensured security of the microscopic anastomosis by immobilizing the vessels. The skin and fat tissue could then easily be tailored and inset with good tissue support of the perforator vessels contained in the harvested muscle and fascia. For ease of positioning and security of vascularity, the free TRAM flap represents the standard for flap shaping and inset.
With advancements in flap harvest and the desire to further limit abdominal morbidity, deep inferior epigastric perforator (DIEP) flaps are now harvested without any abdominal muscle or fascia.1 Although only the perforating vessels are required for flap survival, lack of supporting tissues has created new challenges in flap insetting. By leaving the muscle and fascia that once supported the perforating vessels behind, the vascular supply to the transferred tissue is unprotected and vulnerable. Furthermore, the standard means for securing the abdominal tissues (i.e., suturing the muscle and fascia to the chest wall) is no longer available and alternative methods must be pursued. Simply suturing fat to the chest wall is not as secure and may leave palpable nodules from fat necrosis within the suture. With the DIEP flap, there is more reliance on the skin closure to support the flap.
The most recent of the perforator flaps, the superficial inferior epigastric artery flap, adds an additional challenge in positioning and inset related to the position of its blood supply within the flap.7 Whereas TRAM and DIEP flaps have their blood vessels central in the flap, facilitating inset and placement, the superficial inferior epigastric artery flap has its vessels superficial and peripheral in the flap (Fig. 1). This complicates insetting of the flap in locating the best vascularized tissues properly and avoiding kinking of the pedicle.
Standard free flap inset and placement in breast reconstruction is performed either to the thoracodorsal system or the internal mammary system in most cases, depending on the anatomical situation and surgeon preference.8,9 The goal in selection and flap planning dictates that the best blood supply should be centrally placed or, even better, medially placed to avoid ische-mic problems such as fat necrosis in the medial reconstruction, or to limit its occurrence to a lateral position in the reconstruction, which is easier to revise. For the DIEP flap and free TRAM flap, either recipient site can work. For the superficial inferior epigastric artery flap, however, the internal mammary site is preferred, as it places the best perfused tissues medially and potentially less-well-perfused tissues from across the abdominal midline more laterally10 (Fig. 1). The pedicle length and vessel match are maximized and the microsurgery is facilitated.
