Oncoplastic Flap Surgery: Breast Reconstruction

Description

The aim of this book is to introduce the clinical applications of various flaps in oncoplastic surgery. After a brief introduction of the background and anatomical basis of breast reconstruction, the book shows surgical reconstruction procedures using different types of flaps, for example, deep inferior epigastric perforator (DIEP) flap, profunda artery perforator flap and omentum flap. The great number of representative clinical cases together with high quality operative pictures constitute one of the highlights of this book. These pictures provided with details in flap design, elevation, harvest, transfer, and complications management. Furthermore, the use of Indocyanine green angiography and three-dimensional shaping with autologous tissue transplantation is discussed. Written by a group of experienced oncoplastic surgeons, this book offers a valuable reference work for medical researchers and practitioners in microsurgery, plastic and reconstructive surgery. Foreword 1 Foreword 2 Preface Contents Contributors 1: Breast Reconstruction with Autologous Tissue Transplantation 1.1 Breast Cancer and Mastectomy 1.2 Breast Reconstruction with Autologous Tissue Flap 1.3 Free-Styled Flap 1.3.1 Skin Tube 1.4 Latissimus Dorsi Flap 1.5 Abdominal Flap 1.6 Free Tissue Flap Transplantation 1.7 Perforator Flap Base on the Deep Inferior Epigastric Artery 1.8 Other Abdominal Perforator Flaps 1.9 Muscle Sparing Latissimus Dorsi (MSLD) Flap, Thoracodorsal Artery Perforator Flap, and Intercostal Artery Perforator Flap 1.10 Hip Flap 1.11 Lumbar Artery Perforator Flap 1.12 Thigh Flap 1.13 Transverse Upper Gracilis (TUG) Myocutaneous Flap 1.14 Perforator Flap of Profunda Femoral Artery 1.15 Progress of Breast Reconstruction 1.15.1 Autologous Fat Injection 1.15.2 Upper Limb Lymphedema 1.16 The Future of Breast Reconstruction References 2: History of DIEP Flap in Breast and Chest Wall Reconstruction 2.1 Background and Development of Inferior Abdominal Artery Perforator Flap for Breast Reconstruction and Chest Wall Reconstruction 2.1.1 Advantages and Disadvantages 2.1.2 Indications 2.1.3 Contraindication 2.1.4 Preoperative Planning 2.1.5 Anatomy 2.1.6 Surgical Technique 2.1.7 Postoperative Management 2.1.8 Complications 2.1.9 Summary References 3: The Importance of Preserving Intercostal Nerves 3.1 Process Steps of Actual Surgical Separation of Intercostal Nerves (Figs. 3.4, 3.5, 3.6, 3.7, 3.8, and 3.9) 3.1.1 Case 1: Preserving the Intercostal Nerves When Separating the DIEPs References 4: Raising the DIEP Flap on Cadaver 4.1 Introduction 4.2 Steps of a DIEP FLAP Raising on Cadaver References 5: The DIEA Branching Pattern and Its Relationship to Perforators 5.1 The Number of Perforating Branches of Deep Inferior Epigastric Vessels 5.1.1 Case 1: Anatomical Type of Perforating Branch 5.1.2 Case 2: Multiple Perforator Pattern 5.2 Anatomical Types of DIEPs Based on Running Pattern 5.2.1 Case 3: Muscular Septal Perforating Branch of Deep Inferior Epigastric Artery 5.2.2 Case 4: Muscular Septal Perforating Branch of Inferior Epigastric Artery 5.2.3 Case 5: Superficial Medial Vascular Branch of Deep Inferior Epigastric Artery 5.2.4 Case 6: DIEP Flap Containing Both the Medial and Lateral Perforating Branches References 6: Adjustment of Vascular Body Area of DIEP Flap 6.1 Case 1: Adjustment of Vascular Body Area of DIEP Flap 6.1.1 Anatomical Territory 6.1.2 Hemodynamic Donor Territory 6.1.3 Potential Territory 6.2 Case 2: A DIEP Flap Pedicled with a Paraumbilical Perforator of the Lateral Branch 6.3 Case 3: A DIEP Flap Pedicled with Perforators of the Lateral Branch 6.4 Case 4: A DIEP Flap Pedicled with Lateral Perforators References 7: Various Forms of DIEP Flaps 7.1 Transverse Perforator Flap of Deep Inferior Epigastric Artery 7.1.1 Case 1: Transverse Perforator Flap of Deep Inferior Epigastric Artery 7.2 Vertical DIEP Flap 7.2.1 Case 2: The Vertical DIEP Flap (Figs. 7.16, 7.17, 7.18, 7.19, 7.20, 7.21, 7.22, and 7.23) 7.3 Oblique Design of DIEP Flap 7.3.1 Case 3: An Oblique DIEP Flap with Sensation 7.4 Polyflaps Based on DIEP 7.4.1 Case 4: Polyflaps Based on DIEP 7.4.2 Case 5: Polyflaps DIEP Flap 7.4.3 Case 6: Lobed DIEP Flap 7.5 Microsurgical Debulking of the DIEP Flap 7.5.1 Case 7: Microdissected Thin DIEP Flap with Multiple Perforators 7.5.1.1 Super-Thin Perforator Flap 7.6 De-epithelized DIEP Flap 7.6.1 Case 8: De-epithelized DIEP Flap 7.7 Chimeric DIEP Flap 7.7.1 Case 9: Chimeric DIEP Flap with Muscle Flap (Figs. 7.73, 7.74, 7.75, 7.76, and 7.77) References 8: Modified Auxiliary Incision for Flap Removal 8.1 Case 1: Modified Auxiliary Incision for Raising a DIEP Flap 9: Unilateral Pedicled TRAM Flap Plus Contralateral Free DIEP Flap 9.1 Combined Flap 9.2 Siamese Flap 9.3 Case 1: Pedicled RAM Flap Combined with Free DIEP Flap with the Lateral Thoracic Vessels as Recipient Vessels 9.4 Case 2: Pedicled Rectus Abdominis Flap Combined with Free Perforator Flap of Deep Inferior Epigastric Artery: The Thoracoacromial Vessels as Recipient 9.5 Case 3: Pedicled Rectus Abdominis Flap Combined with Free Perforator Flap of Deep Inferior Epigastric: An Anterior Serratus Branch of the Thoracodorsal Vessels as Recipient References 10: Strategies for Improving Venous Drainage in DIEP Flap for Chest Wall and Breast Reconstruction 10.1 Introduction 10.2 Anatomy Essentials 10.3 Preoperative Management 10.4 Intraoperative Management 10.5 Management of Venous Congestion 10.5.1 Microscopic Exploration 10.5.2 Pressure Reduction 10.5.3 Flap Trimming 10.5.4 Replacement of Vascular Pedicle 10.5.5 Selection and Preparation of Recipient Vessels 10.5.6 Flexible Application of Superficial Epigastric Vein 10.5.7 Non-microsurgical Approach for Flap Salvage 10.5.8 Flap Necrosis and Remedial Measures 10.5.9 Postoperative Management 10.6 Case 1: A DIEP Flap Supercharged Using Ipsilateral Superficial Epigastric Vein 10.7 Case 2: A DIEP Flap with SIEV Revascularization 10.8 Case 3: Breast Reconstruction Using DIEP Flap and SIEV 10.9 Case 4: DIEP Flap Including SIEV for Reconstruction References 11: Bipedicled Turbocharged DIEP Flaps for Unilateral Breast Reconstruction 11.1 Introduction 11.1.1 Turbocharge 11.2 The Indications and Advantages of Turbocharge 11.3 Case 1: Turbocharge 11.4 Case 2: Turbocharged DIEP Flap References 12: Bipedicled Supercharged DIEP Flap for Unilateral Breast Reconstruction 12.1 Indications 12.2 Surgical Methods and Imaging Features of Double Pedicled Perforator Flap of Deep Inferior Epigastric Artery 12.3 Case Study 1: Bipedicled Supercharged DIEP Flap Using the Proximal and Distal Internal Mammary Vessels as Recipient Vessels 12.4 Case Study 2: Supercharged Vascular Anastomosis: The Anterior Serratus Branch of Thoracodorsal Vessel and the Proximal End of Internal Thoracic Vessels Were Used as Recipient Vessels 12.5 Case Study 3: Supercharged DIEP Flap Using Internal Mammary Vessels and Lateral Thoracic Vessels as Recipient 12.5.1 Supercharge 12.5.2 Turbocharge 12.6 Case 4: Bipedicled DIEP Flap for Breast Reconstruction 12.7 Summary References 13: Bilateral Simultaneous Breast Reconstruction with Bilateral DIEP Flaps References 14: Free DIEP Combined with SIEAP Flap for Unilateral Breast Reconstruction 14.1 Indications and Contraindications 14.1.1 Anatomy 14.2 Matters Needing Attention 14.2.1 Perfusion Evaluation 14.2.2 Adjustment of Flap Placement 14.2.3 Abdominal Drainage 14.2.4 Postoperative Monitoring 14.3 Case 1: DIEP + SIEAP Breast Reconstruction 14.3.1 Flap Adjustment 14.4 Case 2: DIEP + SIEAP Breast Reconstruction 2 References 15: Simultaneous Contralateral Breast Reduction/Mastopexy with Unilateral Breast Reconstruction Using Free DIEP Flaps 15.1 Background 15.2 Timing of Operation 15.3 Preoperative Design and Donor Site Preparation References 16: Sensory Reconstruction for the Reconstructed Breast 16.1 Selecting Nerves References 17: Free DIEP Flap with Ilioinguinal Lymphoid Tissue for Breast Reconstruction and Treatment of Upper Limb Lymphedema 17.1 Summary 17.2 Surgical Methods 17.2.1 Flap Design 17.2.2 Receiving Area Preparation 17.2.3 Flap Raising 17.2.4 Breast Reconstruction and Vascular Anastomosis 17.2.5 Postoperative Treatment 17.3 Discussion References 18: Experience Sharing in Handling Difficult Cases of Breast Reconstruction with DIEP Flap 18.1 Risk Avoidance of Breast Reconstruction 18.1.1 Downsides of Flap Raising in This Case 18.1.2 Scheme 1 Summary 18.1.3 Redesign Scheme 2 (Fig. 18.47) 18.1.4 Vascular Pedicle Repair and Repositioning 18.1.5 Experience and Lessons of Surgical Failure 18.2 Summary of the Perioperative Precautions of Breast Reconstruction and Chest Wall Reconstruction 18.2.1 Preoperative Preparation 18.2.2 Postoperative Treatment Plan References 19: Evolution, Anatomy, Advantages and Disadvantages, and Harvest Techniques of Profunda Artery Perforator Flap 19.1 History 19.2 Vascular Anatomy 19.3 Indication 19.4 Preoperative Design 19.5 Operation Process 19.6 Postoperative Care 19.7 Discussion 19.8 Conclusions References 20: Vascular Variations and Approaches of PAP Flap 20.1 Anatomy 20.1.1 Preoperative Planning/Flap Design 20.2 Discussion of Clinical Experience 20.3 Typical Case 1: Medial Femoral Flap Pedicled with Direct Perforating Branch of the Femoral Artery 20.4 Typical Case 2: Adductor Longus Perforator Flap Pedicled with Profunda Femoral Artery 20.5 Typical Case 3: Profunda Femoral Artery Adductor Longus Perforator Gracilis Chimeric Myocutaneous Flap 20.6 Typical Case 4: Profunda Femoral Artery Pedicled Adductor Longus Perforator Chimeric Gracilis Myocutaneous Flap 20.7 Typical Case 5: An Example of Excision of the Gracilis Muscle Perforator Chimeric Myocutaneous Flap 20.8 Typical Case 6: Multi-Perforator Profunda Femoral Artery Perforator Flap with Partial Gracilis Muscle 20.9 Typical Case 7: Gracilis Myocutaneous Flap for Muscle Functional Reconstruction 20.10 Typical Case 8: Pure Gracilis Perforator Flap 20.11 Typical Case 9: Profunda Femoral Artery Pedicled Gracilis Perforator Chimeric Myocutaneous Flap 20.12 Typical Case 10: Gracilis Perforator Chimeric Myocutaneous Flap (Figs. 20.51, 20.52, 20.53, 20.54, 20.55, and 20.56) 20.13 Typical Case 11: Adductor Longus Perforator Chimeric Gracilis Myocutaneous Flap 20.14 Typical Case 12: Adductor Major Perforator Flap Pedicled with Profunda Femoral Artery 20.15 Typical Case 13: Chimeric Gracilis Myocutaneous Flap Pedicled with Perforating Branch of the Adductor Major 20.16 Typical Case 14: Chimeric Gracilis Myocutaneous Flap Pedicled with the Perforating Branch of the Adductor Major While Preserving the Anterior Branch of the Obturator Nerve 20.17 Typical Case 15: Great Adductor Perforator-Embedded Gracilis Myocutaneous Flap 20.18 Typical Case 16: Profunda Femoral Artery Pedicled Adductor Major Perforator Chimeric Adductor Major Myocutaneous Flap 20.19 Typical Case 17: Chimeric Adductor Major Myocutaneous Flap 20.20 Typical Case 18: Supercharged Adductor Major Perforator Myocutaneous Flap 20.21 Typical Case 19: Supercharged Chimeric Adductor Major Myocutaneous Flap 20.22 Typical Case 20: Supercharged Dual-Perforator Pedicled Adductor Major Perforator Flap and Donor Area Reconstructed by the Gracilis Myocutaneous Flap in Relay 20.22.1 Clinical Thinking 20.23 Typical Case 21: Semimembranosus Muscle Chimeric Perforator Myocutaneous Flap 20.24 Conclusion References 21: Transverse Gracilis Musculocutaneous Flap for Breast Reconstruction 21.1 Applied Anatomy 21.2 Flap Design 21.3 Tumor Resection and Recipient Site Preparation 21.4 Flap Cutting 21.5 Breast Reconstruction and Vascular Anastomosis 21.6 Postoperative Treatment 21.7 A Typical Case of Breast Reconstruction with Gracilis Myocutaneous Flap References 22: Single Pedicled Profunda Femoral Artery Perforator Flap for Breast Reconstruction 22.1 A Typical Case of Breast Reconstruction with Single Vessel Pedicled Profunda Femoral Artery Perforator Flap References 23: Free Gracilis Myocutaneous Flap Combined with Profunda Femoral Artery Perforator Flap for Breast Reconstruction 23.1 Gracilis Myocutaneous Flap Combined with Profunda Femoral Artery Perforator Flap for Breast Reconstruction: A Typical Case 23.2 Gracilis Myocutaneous Flap Combined with Profunda Femoral Artery Perforator Flap for Breast Reconstruction: A Typical Case 2 23.3 Gracilis Myocutaneous Flap Combined with Profunda Femoral Artery Perforator Flap for Breast Reconstruction: Typical Case 3 23.4 Gracilis Myocutaneous Flap Combined with Profunda Femoral Artery Perforator Flap for Breast Reconstruction 23.5 Discussion 23.6 Conclusion References 24: Double-Pedicled Profunda Femoral Artery Perforator Flap for Breast Reconstruction 24.1 Surgical Technique 24.2 Double-Vessel Pedicled Profunda Femoral Artery Perforator Flap for Breast Reconstruction: A Typical Case 24.3 Breast Reconstruction with Double-Vessel Pedicled Profunda Femoral Artery Perforator Flap: Typical Case 2 24.4 Double-Vessel Pedicled Profunda Femoral Artery Perforator Flap for Breast Reconstruction: Typical Case 3 24.5 Conclusion References 25: Greater Omental Flap for Breast Reconstruction 25.1 Background 25.2 Indications 25.3 Anatomy 25.4 Advantages and Disadvantages of the Greater Omental Flap and Preoperative Preparation 25.5 Typical Cases of Free Greater Omental Flap 25.6 Design of the Omental Flap for Special Requirements 25.7 Omental Flap Markings 25.8 Surgical Methods 25.9 Precautions for Omental Flap Dissection Technique [27] 25.10 Endoscopic Harvest of the Omental Flap 25.11 Omental Flap Monitoring 25.12 Special Instruments 25.13 Donor Closure and Postoperative Management 25.14 Postoperative Treatment 25.15 Simple Transposition of Pedicled Omental Flap for Breast Reconstruction: Typical Case 1 25.16 Simple Transposition of Pedicled Omental Flap for Breast Reconstruction: Typical Case 2 25.17 Simple Pedicled Omental Flap Transposition for Breast Reconstruction: Typical Case 3 25.18 Simple Transposition of the Pedicled Omental Flap for Breast Reconstruction: Typical Case 4 25.19 Transposition of Pedicled Greater Omentum Flap Combined with Prosthesis Implantation for Breast Reconstruction: Typical Case 1 25.20 Transposition of the Pedicled Omental Flap Combined with Prosthesis Implantation for Breast Reconstruction: Typical Case 2 25.21 Transposition of the Pedicled Omental Flap Combined with Prosthesis Implantation for Breast Reconstruction: Typical Case 3 25.22 Transposition of Pedicled Greater Omentum Flap Combined with Prosthesis Implantation for Breast Reconstruction: Typical Case 4 25.23 Transposition of Pedicled Omental Flap Combined with Prosthesis Implantation for Breast Reconstruction: Typical Case 5 References 26: Application of ICG in Flap Surgery for Oncoplasty 26.1 History of Clinical Application of ICG Angiography 26.1.1 Initial: 1950s, 1960s, and 1970s 26.1.2 Development: Application in Ophthalmology in the 1970s and 1980s 26.1.3 Wide Application: After the 1990s 26.1.4 Clinical Application of ICG in China 26.2 Characteristics of ICG 26.3 Application of ICG Imaging in Breast Reconstruction 26.3.1 Prediction Models and Comparison of Tissue Perfusion During Reconstruction 26.3.2 Application of ICG in Breast Reconstruction 26.3.2.1 ICG Is Used for Breast Reconstruction with Expander and Prosthesis Implantation 26.3.2.2 ICG for Breast Reconstruction with Autologous Tissue Transfer Locate the Vascular Perforator The Perforator Perfusion Area Was Recorded in Real Time To Evaluate the Effect of Microsurgical Anastomosis Postoperative Observation 26.4 ICG Was Applied to Lower Abdominal Flap with Vertical Incision of Cesarean Section: A Typical Case 26.5 ICG Determined the Number of Vascular Pedicles Required for the Flap: A Typical Case 26.6 ICG for Lower Abdominal Flap Transplantation: A Typical Case 26.6.1 Application of ICG During Operation 26.6.2 Selection of ICG Fluorescence Threshold 26.6.3 Precautions for ICG Application 26.7 Economic Factors of ICG in Breast Reconstruction 26.8 The Future of ICG in Breast Reconstruction 26.9 Summary References 27: Shaping for Breast Reconstruction with Autologous Tissue Transplantation 27.1 A Case Study of One-Stage Breast Reconstruction with DIEP Flap Transplantation 27.2 DIEP Skin Flap Transplantation for Secondary Breast Reconstruction 27.3 DIEP Skin Flap Transplantation for Secondary Breast Reconstruction: A Complicated Case 27.4 Extensive Scar Due to Chest Wall Radiotherapy Treated by Secondary Breast Reconstruction by Autologous Tissue Flap Transplantation 27.4.1 Difficulties in Preoperative Evaluation 27.4.2 Preoperative Questions 27.4.3 Preoperative Design Response 27.5 Real Difficulties Encountered During Operation 27.6 Gracilis Myocutaneous Flap Combined with Profunda Femoral Artery Perforator Flap for Breast Reconstruction: A Typical Case 27.7 Conclusion References