Refinements in Microvascular Breast Reconstruction
Joseph J. Disa, MD Memorial Sloan-Kettering Cancer Center New York, New York
I have nothing to di...
Introduction • Advances in TRAM flaps have sought to improve • Flap blood flow • Abdominal wall morbidity
• Abdominal morbidity can be problematic after rectus muscle harvest • Hernia/laxity • Weakness • Pain/prolonged recovery
Introduction
Pedicled TRAM
Introduction
Free/Muscle Sparing TRAM
Free TRAM
Muscle Sparing Free TRAM MS2
Free TRAM
Free TRAM MS2
Free TRAM MS2
Free TRAM MS2
Perforator Anatomy
DIEP Flap
Introduction • DIEP Æ inclusion of muscle in a flap designed to replace skin and fat is NOT necessary • In most instances dominant perforating vessels can be identified and dissected • Smaller perforating vessels are ligated • Identification of dominant perforators remains subjective
Perforator Anatomy Muscle Sparing TRAM
DIEP
Introduction • DIEP is the evolution of TRAM flap breast reconstruction
Pedicle TRAM
Free TRAM
Musclesparing TRAM
DIEP
Selection Process • • • • • • •
Pedicled TRAM Bipedicled TRAM Free TRAM Muscle Sparing TRAM DIEP flap SIEA flap Which flap is best?
Selection Process • • • • • • • •
Pedicled TRAM Bipedicled TRAM Free TRAM Muscle Sparing TRAM DIEP flap SIEA flap Which flap is best? DEPENDS!! There is a role for each option depending on patient/anatomic circumstances
Patient Selection • Patient selection same as msTRAM flap • Preoperative consultation • msTRAM vs. DIEP flap depending on anatomic findings during operation • pTRAM if recipient vessels not available
Recipient Vessels • Microsurgical anastomosis to the IMA/V or TDA/V • CRITICAL to dissect out vessels prior to committing to free flap • Left internal mammary vein is not usable for microsurgery in 10-15% or patients
Recipient Vessels
Operative Dissection • Intraoperative identification major perforators • No perforators ligated (intentionally) until vascular anatomy defined • Decision made to proceed with DIEP vs. ms TRAM based on • vascular anatomy • flap response to dissection • Reconstructive requirements
How Many Perforators are Enough? • Depends • Perforator selection is subjective • Basic principles • Significant perforator (vein greater than 1mm, artery 0.5-1mm) • Dominant vessels clearly identifiable • I get worried when more than 5 identical vessels are present • Be weary of ligating major perforating vessels
• Hand held Doppler may be helpful • Temporarily clamp selected vessels and assess flow?
Number of Perforators • Sometimes (~25%) a single large perforator maybe present and adequate • Usually 2 (~50%) or 3 (~25%) dominant vessels • If no dominant vessels identified Æabandon DIEP flap dissection and proceed with msTRAM
Number of Perforators
Number of Perforators
Dissection • Dissect from lateral to medial / medial to lateral • Assistant pulls flap away from surgeon to expose perforators • Use cutting electrocautery on pinpoint • Gentle upward traction on the flap and applied pressure with the thumb accomplishes most of the work
Dissection
Dissection • Once both lateral rows dissected, size and number of lateral row perforators assessed • May elect to proceed with DIEP based on lateral perforators if adequate in size • If lateral row appears to be inadequate, medial row vessels dissected after umbilicus cut out
Dissection • Fascia is incised around perforator(s) • Rim of fascia vs. exit point of perforator
• Fascial incision extended to allow wide exposure • Anterior abdominal fascia is dissected from the underlying muscle
Dissection • Perforator dissection begun with most distal perforator • This way an error will not wipe out proximal vessels
• Anterior Dissection to expose vessel(s) • Medial and lateral dissection next • Posterior dissection performed last
Dissection
DIEP flap
DIEP flap • Flap harvested on single perforator • Rectus muscle preserved
DIEP flap • Microvascular anastomoses to internal mammary vessels • 3rd rib cartilage removed for exposure
DIEP flap • Primary closure of fascia without tension • Interrupted 0 ethibond
DIEP flap
msTRAM vs. DIEP
Bilateral DIEP
Right DIEP / Left SIEA
MSKCC Experience 1985-2009
Breast Reconstruction with Tissue Transfer 1985
~
Unilateral
Bilateral
1
1989 Total
Single Pedicle
9
11
Double Pedicle
8
8
Supercharged
3
3
Free Flap
2
2
n=24
12% 8% 34% 46%
DIEP Total
1985 ~ 1989
22
1
24
Breast Reconstruction with Tissue Transfer 1990
~
Unilateral
Bilateral
1994
1990 ~ 1994
Total
n=128 Single Pedicle
33
9
51
Double Pedicle
17
SuperCharged
22
1
24
Free Flap
34
1
36
106
11
128
17
28% 19% 13%
40%
DIEP Total
Breast Reconstruction with Tissue Transfer 1995
~
Unilateral
Bilateral
1999 1995 ~ 1999
Total
n=197 Single Pedicle
90
4
Double Pedicle
7
7
SuperCharged
27
27
Free Flap
59
3
98
65
33% 13% 4% 50%
DIEP Total
183
7
197
Breast Reconstruction with Tissue Transfer 2000
~
Unilateral
Bilateral
2005 Total
2000 ~ 2005 n=256
Single Pedicle
49
2
53
Double Pedicle
18%
SuperCharged
7
Free Flap
96
7 27
150
DIEP
30
8
46
Total
182
37
256
59%
20% 2 %
Breast Reconstruction with Tissue Transfer 2006
~
Unilateral
Bilateral
2009 Total
2006 ~ 2009 n=318
Single Pedicle
11
3
17
SuperCharged
2
1
4
Free Flap
80
35
150
DIEP
83
32
147
Total
176
71
318
Double Pedicle
46% 5% 1 %
47%
Breast Reconstruction with Tissue Transfer n = 605
Breast Reconstruction with Tissue Transfer 2000 – 2003 n=97
2004-200 n=109
2006-2009 n=307
Int-mammary
24 (25%)
73 (67%)
258 (84%)
Thoracodorsal
73 (75%)
36 (33%)
49 (16%)
Thoracodorsal
2006-2009
Int-Mammary
2004-2005
2000-2003
(%)0
20
40
60
80
100
Patient Examples
DIEP
DIEP after Nipple Areola Recon
DIEP after Nipple Areola Recon
Bilateral DIEP
Bilateral DIEP
DIEP pre op RTX on left
DIEP post op
DIEP post op
DIEP after Nipple Areola reconstruction
DIEP after Nipple Areola reconstruction
s/p Right BCT Bilat Breast Reconstruction with DIEP Flap
Preop
DIEP&NAC (Post)
Wise Pattern Mastectomy after BCT DIEP Flap and Reduction
10/4/2004
5/17/2004 DIEP&NAC + Reduction
Wise Pattern Mastectomy Breast Reconstruction with DIEP Flap
DIEP & NAC (Post)
Bilat DIEP
Bilateral DIEP + NAR
Bilat DIEP
Bilat DIEP
Left BCT / Bi-DIEP
Right DIEP + NAR
Capsular Contracture / DIEP salvage
L 410 mf – convert to DIEP
Bilat DIEP
Right DIEP
R delayed / Bi DIEP
L DIEP + NAR
Left DIEP
L DIEP preop
L DIEP post op
R DIEP
R DIEP
Bi DIEP
CONCLUSIONS • DIEP flap breast reconstruction is safe in selected patients • Intraoperative assessment of vascular anatomy is critical • Intramuscular dissection can be simplified by using a structured approach
CONCLUSIONS
• A well healed msTRAM flap is still better than a dead DIEP flap
What about donor site morbidity?
Comparison of SIEA, DIEP, ms free TRAM • Blinded prospective study of 234 patients • Evaluation preop and one year post op • Objective abdominal strength testing
Comparison of SIEA, DIEP, ms free TRAM • Manual Muscle Function Test • Functional Independence Measure • SF-36
Comparison of SIEA, DIEP, ms free TRAM • 234 patients • 157 reconstructions • 82 bilateral
Comparison of SIEA, DIEP, ms free TRAM MOST IMPAIRMENT
F TRAM / F TRAM F TRAM / DIEP DIEP / DIEP DIEP / SIEA
VTE in breast reconstruction • PE incidence: 0% – Cohort study, immediate TRAM flap (Kim et al., 2009)
• Overall incidence of VTE: 0.8% – Retrospective study – Mostly pedicled TRAM flaps (Liao et al., 2008)
• DVT incidence in microsurgical breast reconstruction?
Objectives 1. Objectively determine the incidence of DVT in microsurgical breast reconstruction patients. 2. Evaluate the incidence of complications associated with the use of low molecular weight heparin (LMWH) 3. Evaluate the usefulness of the duplex ultrasound as a screening tool in this patient population.
Materials & Methods • Cohort study • Patient population: – Women undergoing abdominally-based autologous microsurgical breast reconstruction – Single tertiary institution (cancer center)
• Study period: – December 1997 to May 2009
Materials & Methods ∗ Inclusion criteria: ∗ All breast cancer and non-cancer patients undergoing: ∗ Free TRAM flap ∗ Free muscle-sparing TRAM flap ∗ DIEP flap
2. Sequential compressive devices (SCDs) 3. Early post-operative ambulation
Caprini Risk Assessment Model
Materials & Methods • Intervention group: – Bilateral lower extremity duplex ultrasound (DUS) before hospital discharge • Or at any point in the post-operative period if high clinical suspicion
• Control group: – Bilateral lower extremity DUS only in the case of high clinical suspicion
Results
Patient characteristics
* p < 0.04
Surgical Diagnosis
p value = 0.01
Breast Cancer Stage
Surgical Procedures (%)
Length of anesthesia (h)
Caprini score • No statistically significant difference in both groups: Intervention Group
Control Group
p value
7.6 0.9
7.7 1.2
0.12 -
Mean Caprini score Standard Deviation
Highest risk group according to Caprini et al. : predicted DVT incidence between 4080%
Complications (%)
DVT Subgroup Characteristics Flap
Anesthesia Cancer stage BMI
Patient A
Patient B
Patient C
Patient D
Immediate bilateral DIEP
Immediate unilateral TRAM
Immediate unilateral TRAM
Delayed unilateral TRAM
12 h
10 h
7h
7h
Prophylactic
Stage I
Stage 0
Stage IIIB 28.3
27.1
25.7
23.5
Caprini score
6
8
7
9
Tobacco use
No
No
Ex-smoker
Active
Posterior tibial vein
Possibly chronic
Midcalf DVT
Midcalf DVT
DVT
Number Needed to Screen (NNS) • Number of people that need to be screened for a given duration to diagnose one adverse event. • NNS = 1 ⁄ Absolute Risk Reduction DVT incidence
Control Group
Intervention Group
0%
3.4%
Absolute Risk Reduction
NNS (95% CI)
- 3.4%
- 29.4 (-833, -15)
Conclusions • DVT incidence: – 3.4% in the first 5 post-operative days – All events were asymptomatic calf DVTs
• Triple thromboprophylaxis: – Safe • 5% reoperative hematoma rate – Effective • Lower DVT incidence than predicted by the Caprini model • No PE or mortality diagnosed in this study
GAP Flap Breast Reconstruction
SGAP – superior gluteal artery perforator flap
Breast Reconstruction • S-GAP Reconstruction – Advantages • Donor site well hidden • Usually sufficient tissue for reconstruction even in thin patients • Faster recovery than DIEP flap • No risk for hernia • Thicker tissue results in good projection in most cases
Breast Reconstruction • S-GAP Reconstruction – Disadvantages • Slightly longer operative time 5-7 hours • Technically more demanding – greater vessel mismatch at donor and recipient site • In my practice, one side performed at a time • Success rate less than DIEP flap • Not widely available for patients
S-GAP Recipient Site
S-GAP Flap
Donor Site Markings and Landmarks
Flap Inset with Anastamoses and Doppler Confirmation
S-GAP Technique
Flap Salvage Manuevers • Cephalic vein turndown for venous outflow • Saphenous vein interposition grafts for clotted segments • Thoracodorsal to serratus arterial grafts for step-down mismatch • Use of venous coupler device for vein mismatch
Patient Examples
Bilateral S-GAP
Patient Examples
Bilateral S-GAP
Bilateral SGAP
Patient Examples • L free TRAM 1997 after mastectomy for breast cancer • R SGAP 2000 after prophylactic mastectomy
Patient Examples
Patient Examples
Left S-GAP
Patient Examples
Bilateral S-GAP
Patient Examples
DIEP & Delayed SGAP
Delayed SGAP
Patient Examples
• •
bilateral DIEP following bilateral mastectomies for L breast cancer 2001- L DIEP nonviable delayed L SGAP 2002
Patient Examples
Patient Examples
110 Consecutive Superior Gluteal Artery Perforator (SGAP) Flaps for Breast Reconstruction: A Single Surgeon’ Surgeon’s Experience World Society for Reconstructive Microsurgery Athens, Greece 2007 Bernard W. Chang, MD Director, Plastic & Reconstructive Surgery at Mercy Clinical Associate Professor of Surgery Johns Hopkins University School of Medicine
Kathy Huang, MD Bethesda, MD
Methods • Retrospective review of all SGAP flaps performed from July 1999 to December 2006 • 110 SGAP flaps performed on 95 patients for breast reconstruction • Mean age = 47.5 yrs (range 31-63)
Methods • • • • •
Hypertension Active Smokers History of Smoking Pre-op RT Post-op RT
12.2% 13.2% 22.6% 21.7% 2.8%
BMI of SGAP Patients
(Mean 24.7)
25 # patients 20 15 10 5 0 17
19
21
23
25
27
29
31
33
35
37
39
Methods • Timing of SGAP Reconstruction – Immediate – Delayed
45.3% 54.7%
Methods • Indications for SGAP flap – Not enough abdominal tissue – Previous abdominal flap – Previous cosmetic surgery • Abdominoplasty • Abdominal liposuction
– Abdominal incisions – Patient preference
44.3% 37.7% 9.5%
5.7% 3.8%
5.7% 2.8%
Results • Operative Length – 8.2 hrs (avg) first 55 pts – 6.2 hrs (avg) last 55 pts
Conclusion • SGAP flap breast reconstruction is a viable alternative for producing an aesthetic autologous breast reconstruction • Flap failure is associated with BMI>30 and should be avoided in these pts • Flap reliability improves with experience
