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Defining Vascular Dominance in Challenging Abdominal Based Breast Reconstructions with Uncertain Vascular Pedicle Reliability
Hashem AM, Abedi N, Djohan R
Cleveland Clinic
2016-01-30
Presenter: Ahmed M Hashem
Affidavit:
I certify that the material proposed for presentation in this abstract has not been published in any scientific journal or previously presented at a major meeting.
Director Name: Risal Djohan
Author Category: Fellow Plastic Surgery
Presentation Category: Clinical
Abstract Category: Breast (Aesthetic and Recon.)
Background:
Based on vascular inflow different abdominal flaps can be harvested. Inadequate perfusion can lead to flap loss or fat necrosis. Usually, a reliable pedicle can be easily identified. Occasionally, cases with multiple laparotomies present with challenging anatomy, where reliable vascular perfusion is less certain. We introduce an intraoperative approach to define vascular dominance in this setting.
Methods:
Each of the three major nutrient vessels (superior epigastric, deep inferior epigastric, and superficial inferior epigastric arteries) as well as the intercostals are surgically identified and controlled. Temporary sequential clamping of the vessels allows precise perfusion assessment based on each vessel independently. Color, capillary-refill, dermal bleeding, tissue oximetry (Near Infrared Spectroscopy), and indocyanine fluorescence are compared and flaps are harvested according to identified vascular dominance.
Case model:
A 63 year old female with previous laparotomies was undergoing bilateral immediate autologous breast reconstruction. She had imaging confirmed inadequate deep system perforators precluding DIEP (Deep Inferior Epigastric Perforator), and MS-TRAM (Muscle Sparing-Transverse Rectus Abdominis) flap harvest. Using our approach, the SIEA (superficial inferior epigastric artery) was identified as the dominant vascular pedicle. Bilateral SIEA flaps were successfully harvested. Postoperative perfusion was uneventful. One year follow-up showed no fat necrosis and excellent abdominal wall function.
Conclusion:
With this technique, flap perfusion can be precisely assessed, and vascular dominance can be accurately defined. The choice of harvesting a free SIEA flap, a free DIEP or MS-TRAM, or a pedicled TRAM is not exhausted, no bridges are burnt, and a lifeboat is always available.
