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Bilateral superior epigastric pedicle perforator flaps for total chest wall coverage
Journal of Plastic, Reconstructive & Aesthetic Surgery (2011) 64, 1104e1107
CASE REPORT
Bilateral superior epigastric pedicle perforator flaps for total chest wall coverage* Georgette Oni, Rohit Sharma, Roshni Rao, Jacob Unger, Michel Saint-Cyr* Department of Plastic Surgery, UT Southwestern Medical Center, 1801 Inwood Dr., Dallas, TX 75392, USA Received 1 October 2010; accepted 30 November 2010
KEYWORDS Superior epigastric artery; Perforasome; Perforator flap; Chest wall reconstruction; Free-style flaps
Summary The superior epigastric artery (SEA), a terminal branch of the internal mammary artery, is analogous to the deep inferior epigastric artery (DIEA) in that it supplies a large number of perforators that are clustered together. This allows tissue from the superior abdomen to be used as a pedicled flap for reconstruction. A reliable and well-perfused pedicled flap can be based on this cluster of perforators, hence the term ‘pedicle cluster perforator flap’. We present a case of a patient with recurrent angiosarcoma, who required total anterior chest wall reconstruction. This was achieved using bilateral pedicled SEA perforator flaps for complete coverage. To our knowledge, this is the first documented case of bilateral pedicled perforator flap reconstruction for complete chest wall reconstruction. Published by Elsevier Ltd on behalf of British Association of Plastic, Reconstructive and Aesthetic Surgeons.
Any major axial vessel will provide a rich supply of perforators, which can form the basis for either a free or pedicle perforator flap. The anterior abdominal wall is well described as having dual supply from the inferior and superior epigastric arteries.1 While the deep inferior epigastric artery (DIEA) is often the dominant supply, pedicled flaps raised on the superior epigastric artery (SEA) can be used for chest wall reconstruction. There are several case reports *
This work has not been presented wholly or in part at any meetings. * Corresponding author. Tel.: þ214 645 3115; fax: þ214 645 3105. E-mail address: [email protected] (M. Saint-Cyr).
demonstrating its use for small-to-moderate size defects.2e5 However, using our knowledge of vascular territories, it is possible to raise large area flaps using upper abdominal soft tissue to reconstruct major defects of the chest wall. We present a case of a patient who required total anterior chest wall reconstruction where we were able to achieve complete coverage using bilateral pedicled SEA perforator flaps.
Case report A 75-year-old patient presented with a previous history of breast cancer (T2N0M0) for which she underwent a left partial mastectomy and sentinel node biopsy followed by
1748-6815/$ - see front matter Published by Elsevier Ltd on behalf of British Association of Plastic, Reconstructive and Aesthetic Surgeons. doi:10.1016/j.bjps.2010.11.025
Bilateral superior epigastric pedicle perforator flaps for total chest wall coverage radiotherapy. Eight years after completing radiotherapy, she subsequently developed angiosarcoma of the left breast, which was treated with total left mastectomy, and this defect was reconstructed with a pedicled latissimus dorsi flap. One year later, she developed a biopsy-proven recurrence of the angiosarcoma, which now extended from the left chest wall to the right breast (Figure 1). Her past surgical history included an open appendectomy, partial hysterectomy, bilateral salpingo-oophorectomy, through horizontal abdominal incisions, inguinal hernia repair as well as a hiatal hernia repair through a midline abdominal incision. Other past medical history included ongoing medical treatment for reflux, a body mass index (BMI) >35 kg m2 and asthma. The surgical oncology department performed a rightbreast total mastectomy and sentinel lymph node biopsy for formal staging, in addition to a wide local excision of her angiosarcoma, leaving an en bloc defect spanning the width of her chest from the inframammary folds to the clavicles bilaterally, extending up to Louis’ angle at the neck level (Figure 2). Ribs were exposed on the left hemichest as well as cartilage, as were the strap muscles in the neck and tendinous insertions of strap muscles at the neck level. In total, the defect measured approximately 80 cm by 20 cm (1600 cm2).
Figure 1 Pre-operative photograph demonstrating area of the chest wall to be resected. Note previous left total mastectomy defect that was reconstructed with a pedicled LD flap, and scars to abdomen from previous surgeries, preventing the use of lower-abdominal based flaps for reconstruction.
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Figure 2 Intra-operative photograph illustrating extent of chest wall resection and size of planned bilateral perforator flaps. X marks Doppler signal for SEA perforators.
Surgical options and reconstructive technique The patient’s previous multiple abdominal surgeries had left numerous scars on her lower abdomen, which prevented the use of any lower-abdominal-based pedicle flaps due to uncertainty in vascular supply to the anterior abdominal wall. The considerable size of the defect and her previous surgeries to the chest region meant that other commonly used flaps such as pectoralis major, or latissimus dorsi, could not be used as they had been resected or would not provide sufficient coverage. Therefore, as she had excessive skin laxity posterolaterally and a virgin upper abdomen, it was decided to perform bilateral pedicle perforator flaps based on SEA perforators. This reconstructive option offered total coverage of the chest wall defect without the need for skin grafting, and offered reduced donor site morbidity as no underlying muscle was harvested. A pencil Doppler was used to locate the SEA perforators just below the costal margin bilaterally. The flap longitudinal axis was perpendicular to the midline overlying the branches of the SEA. Each flap’s dimensions were 38 cm in length and 15 cm in diameter, bilaterally (Figure 2). The superior epigastric perforators were not skeletonised but had a generous cuff of fatty tissue where they entered the base of the flaps to maximise venous return and to maximise arterial perfusion of the flap. This differs from the technique used to raise propeller flaps in which a dominant perforator is identified. The circumferential incisions through skin and dermis to the subcutaneous level allowed enough mobility for a 90 rotation of the flap. The flaps were inset with 2/0 Vicryl sutures and stapled peripherally; two drains were left in place on each side (Figure 3). The patient’s postoperative recovery was uneventful, and she was discharged from the hospital 4 days later. At her follow-up in clinic, she had well-vascularised flaps with no signs of skin necrosis. There was some wound dehiscence in the skin that had come from her previous mastectomy sites, but this went on to heal with secondary intention after local debridement (Figure 4).
1106
G. Oni et al. solving complex reconstructive challenges. Their use allows the conversion from using a finite number of source-arterydependent classic flaps to ad hoc freestyle pedicled perforator flaps, increasing our reconstructive options.6e8 The SEA is very much like the deep inferior epigastric artery (DIEA) in that it supplies a large number of perforators, allowing tissue from the superior abdomen to be used as a free or pedicled flap. Conversion to a perforator flap without the use of the underlying rectus muscle as a vascular carrier is a natural evolution in the use of this workhorse source artery. This eliminates a large portion of donor-site morbidity as no muscle is harvested. To maximise the reliability of pedicled perforator flaps based on the superior SEA, the longitudinal axis of the skin paddle should be designed along lines of maximal skin laxity, which naturally are perpendicular to the midline following natural tissue rolls. We found that the maximum numbers of perforators originating from the SEA were found clustered around the xiphisternum as has been previously described.9,10 Flap dissection is performed until adequate mobilisation is achieved reducing the risk of venous congestion, and minimising the risk of any pedicle kinking. The flap was based on a cluster of perforators, rather than one dominant pedicle, hence the term ‘pedicle cluster perforator flap’. Perforators do not need to be skeletonised during flap transfer, and as much tissue as possible should be kept to the base of the flap to minimise any venous congestion in the arterial inflow problem and arterial ischaemia.
Figure 3 Bilateral superior epigastric artery pedicle perforator flaps rotated 90 counter-clockwise to reconstruct chest wall defect. Note pink, well-perfused flaps, with no evidence of congestion at end of surgery.
Discussion With increased knowledge of vascular anatomy, as well as perfusion characteristics and topographic location of perforators, pedicled perforator flaps have become an extremely useful adjunct in our reconstructive armamentarium for
Conclusion This case report demonstrates the potential large size that a SEA pedicled perforator flap can achieve for soft-tissue reconstruction. Knowledge of the anatomical location and Doppler confirmation of the perforators allows this flap to be raised as a ‘pedicle cluster perforator flap’ without the need for their direct visualisation. We have demonstrated its use for large chest-wall defects and as such represents a useful surgical adjunct in chest wall reconstruction.
Ethical approval None.
Funding None.
Conflict of interest statement None of the authors have any conflicts of interest to declare.
References
Figure 4 Patient at 3 month follow-up with a well healed pedicle perforator flaps and stable chest wall coverage.
1. Rozen WM, Ashton MW, Taylor GI. Reviewing the vascular supply of the anterior abdominal wall: redefining anatomy for increasingly refined surgery. Clin Anat 2008;21(2):89e98. 2. Hallock GG. The superior epigastric (rectus abdominis) muscle perforator flap. Ann Plast Surg 2005;55(4):430e2.
Bilateral superior epigastric pedicle perforator flaps for total chest wall coverage 3. Uemura T. Superior epigastric artery perforator flap: preliminary report. Plast Reconstr Surg 2007;120(1):1ee5e. 4. Hamdi M, Van Landuyt K, Ulens S, Van Hedent E, Roche N, Monstrey S. Clinical applications of the superior epigastric artery perforator (SEAP) flap: anatomical studies and preoperative perforator mapping with multidetector CT. J Plast Reconstr Aesthet Surg 2009;62(9):1127e34. 5. Woo KJ, Pyon JK, Lim SY, Mun GH, Bang SI, Oh KS. Deep superior epigastric artery perforator ‘propeller’ flap for abdominal wall reconstruction: a case report. J Plast Reconstr Aesthet Surg 2010;63(7):1223e6. 6. Wei FC, Mardini S. Free-style free flaps. Plast Reconstr Surg 2004;114(4):910e6.
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7. Bravo FG, Schwarze HP. Free-style local perforator flaps: concept and classification system. J Plast Reconstr Aesthet Surg 2009;62(5):602e8. discussion 9. 8. Wallace CG, Kao HK, Jeng SF, Wei FC. Free-style flaps: a further step forward for perforator flap surgery. Plast Reconstr Surg 2009;124(Suppl. 6):e419e26. 9. Boyd JB, Taylor GI, Corlett R. The vascular territories of the superior epigastric and the deep inferior epigastric systems. Plast Reconstr Surg 1984;73(1):1e16. 10. Wong C, Saint-Cyr M, Rasko Y, Mojallal A, Bailey S, Myers S, et al. Three- and four-dimensional arterial and venous perforasomes of the internal mammary artery perforator flap. Plast Reconstr Surg 2009;124(6):1759e69.
CASE REPORT
Bilateral superior epigastric pedicle perforator flaps for total chest wall coverage* Georgette Oni, Rohit Sharma, Roshni Rao, Jacob Unger, Michel Saint-Cyr* Department of Plastic Surgery, UT Southwestern Medical Center, 1801 Inwood Dr., Dallas, TX 75392, USA Received 1 October 2010; accepted 30 November 2010
KEYWORDS Superior epigastric artery; Perforasome; Perforator flap; Chest wall reconstruction; Free-style flaps
Summary The superior epigastric artery (SEA), a terminal branch of the internal mammary artery, is analogous to the deep inferior epigastric artery (DIEA) in that it supplies a large number of perforators that are clustered together. This allows tissue from the superior abdomen to be used as a pedicled flap for reconstruction. A reliable and well-perfused pedicled flap can be based on this cluster of perforators, hence the term ‘pedicle cluster perforator flap’. We present a case of a patient with recurrent angiosarcoma, who required total anterior chest wall reconstruction. This was achieved using bilateral pedicled SEA perforator flaps for complete coverage. To our knowledge, this is the first documented case of bilateral pedicled perforator flap reconstruction for complete chest wall reconstruction. Published by Elsevier Ltd on behalf of British Association of Plastic, Reconstructive and Aesthetic Surgeons.
Any major axial vessel will provide a rich supply of perforators, which can form the basis for either a free or pedicle perforator flap. The anterior abdominal wall is well described as having dual supply from the inferior and superior epigastric arteries.1 While the deep inferior epigastric artery (DIEA) is often the dominant supply, pedicled flaps raised on the superior epigastric artery (SEA) can be used for chest wall reconstruction. There are several case reports *
This work has not been presented wholly or in part at any meetings. * Corresponding author. Tel.: þ214 645 3115; fax: þ214 645 3105. E-mail address: [email protected] (M. Saint-Cyr).
demonstrating its use for small-to-moderate size defects.2e5 However, using our knowledge of vascular territories, it is possible to raise large area flaps using upper abdominal soft tissue to reconstruct major defects of the chest wall. We present a case of a patient who required total anterior chest wall reconstruction where we were able to achieve complete coverage using bilateral pedicled SEA perforator flaps.
Case report A 75-year-old patient presented with a previous history of breast cancer (T2N0M0) for which she underwent a left partial mastectomy and sentinel node biopsy followed by
1748-6815/$ - see front matter Published by Elsevier Ltd on behalf of British Association of Plastic, Reconstructive and Aesthetic Surgeons. doi:10.1016/j.bjps.2010.11.025
Bilateral superior epigastric pedicle perforator flaps for total chest wall coverage radiotherapy. Eight years after completing radiotherapy, she subsequently developed angiosarcoma of the left breast, which was treated with total left mastectomy, and this defect was reconstructed with a pedicled latissimus dorsi flap. One year later, she developed a biopsy-proven recurrence of the angiosarcoma, which now extended from the left chest wall to the right breast (Figure 1). Her past surgical history included an open appendectomy, partial hysterectomy, bilateral salpingo-oophorectomy, through horizontal abdominal incisions, inguinal hernia repair as well as a hiatal hernia repair through a midline abdominal incision. Other past medical history included ongoing medical treatment for reflux, a body mass index (BMI) >35 kg m2 and asthma. The surgical oncology department performed a rightbreast total mastectomy and sentinel lymph node biopsy for formal staging, in addition to a wide local excision of her angiosarcoma, leaving an en bloc defect spanning the width of her chest from the inframammary folds to the clavicles bilaterally, extending up to Louis’ angle at the neck level (Figure 2). Ribs were exposed on the left hemichest as well as cartilage, as were the strap muscles in the neck and tendinous insertions of strap muscles at the neck level. In total, the defect measured approximately 80 cm by 20 cm (1600 cm2).
Figure 1 Pre-operative photograph demonstrating area of the chest wall to be resected. Note previous left total mastectomy defect that was reconstructed with a pedicled LD flap, and scars to abdomen from previous surgeries, preventing the use of lower-abdominal based flaps for reconstruction.
1105
Figure 2 Intra-operative photograph illustrating extent of chest wall resection and size of planned bilateral perforator flaps. X marks Doppler signal for SEA perforators.
Surgical options and reconstructive technique The patient’s previous multiple abdominal surgeries had left numerous scars on her lower abdomen, which prevented the use of any lower-abdominal-based pedicle flaps due to uncertainty in vascular supply to the anterior abdominal wall. The considerable size of the defect and her previous surgeries to the chest region meant that other commonly used flaps such as pectoralis major, or latissimus dorsi, could not be used as they had been resected or would not provide sufficient coverage. Therefore, as she had excessive skin laxity posterolaterally and a virgin upper abdomen, it was decided to perform bilateral pedicle perforator flaps based on SEA perforators. This reconstructive option offered total coverage of the chest wall defect without the need for skin grafting, and offered reduced donor site morbidity as no underlying muscle was harvested. A pencil Doppler was used to locate the SEA perforators just below the costal margin bilaterally. The flap longitudinal axis was perpendicular to the midline overlying the branches of the SEA. Each flap’s dimensions were 38 cm in length and 15 cm in diameter, bilaterally (Figure 2). The superior epigastric perforators were not skeletonised but had a generous cuff of fatty tissue where they entered the base of the flaps to maximise venous return and to maximise arterial perfusion of the flap. This differs from the technique used to raise propeller flaps in which a dominant perforator is identified. The circumferential incisions through skin and dermis to the subcutaneous level allowed enough mobility for a 90 rotation of the flap. The flaps were inset with 2/0 Vicryl sutures and stapled peripherally; two drains were left in place on each side (Figure 3). The patient’s postoperative recovery was uneventful, and she was discharged from the hospital 4 days later. At her follow-up in clinic, she had well-vascularised flaps with no signs of skin necrosis. There was some wound dehiscence in the skin that had come from her previous mastectomy sites, but this went on to heal with secondary intention after local debridement (Figure 4).
1106
G. Oni et al. solving complex reconstructive challenges. Their use allows the conversion from using a finite number of source-arterydependent classic flaps to ad hoc freestyle pedicled perforator flaps, increasing our reconstructive options.6e8 The SEA is very much like the deep inferior epigastric artery (DIEA) in that it supplies a large number of perforators, allowing tissue from the superior abdomen to be used as a free or pedicled flap. Conversion to a perforator flap without the use of the underlying rectus muscle as a vascular carrier is a natural evolution in the use of this workhorse source artery. This eliminates a large portion of donor-site morbidity as no muscle is harvested. To maximise the reliability of pedicled perforator flaps based on the superior SEA, the longitudinal axis of the skin paddle should be designed along lines of maximal skin laxity, which naturally are perpendicular to the midline following natural tissue rolls. We found that the maximum numbers of perforators originating from the SEA were found clustered around the xiphisternum as has been previously described.9,10 Flap dissection is performed until adequate mobilisation is achieved reducing the risk of venous congestion, and minimising the risk of any pedicle kinking. The flap was based on a cluster of perforators, rather than one dominant pedicle, hence the term ‘pedicle cluster perforator flap’. Perforators do not need to be skeletonised during flap transfer, and as much tissue as possible should be kept to the base of the flap to minimise any venous congestion in the arterial inflow problem and arterial ischaemia.
Figure 3 Bilateral superior epigastric artery pedicle perforator flaps rotated 90 counter-clockwise to reconstruct chest wall defect. Note pink, well-perfused flaps, with no evidence of congestion at end of surgery.
Discussion With increased knowledge of vascular anatomy, as well as perfusion characteristics and topographic location of perforators, pedicled perforator flaps have become an extremely useful adjunct in our reconstructive armamentarium for
Conclusion This case report demonstrates the potential large size that a SEA pedicled perforator flap can achieve for soft-tissue reconstruction. Knowledge of the anatomical location and Doppler confirmation of the perforators allows this flap to be raised as a ‘pedicle cluster perforator flap’ without the need for their direct visualisation. We have demonstrated its use for large chest-wall defects and as such represents a useful surgical adjunct in chest wall reconstruction.
Ethical approval None.
Funding None.
Conflict of interest statement None of the authors have any conflicts of interest to declare.
References
Figure 4 Patient at 3 month follow-up with a well healed pedicle perforator flaps and stable chest wall coverage.
1. Rozen WM, Ashton MW, Taylor GI. Reviewing the vascular supply of the anterior abdominal wall: redefining anatomy for increasingly refined surgery. Clin Anat 2008;21(2):89e98. 2. Hallock GG. The superior epigastric (rectus abdominis) muscle perforator flap. Ann Plast Surg 2005;55(4):430e2.
Bilateral superior epigastric pedicle perforator flaps for total chest wall coverage 3. Uemura T. Superior epigastric artery perforator flap: preliminary report. Plast Reconstr Surg 2007;120(1):1ee5e. 4. Hamdi M, Van Landuyt K, Ulens S, Van Hedent E, Roche N, Monstrey S. Clinical applications of the superior epigastric artery perforator (SEAP) flap: anatomical studies and preoperative perforator mapping with multidetector CT. J Plast Reconstr Aesthet Surg 2009;62(9):1127e34. 5. Woo KJ, Pyon JK, Lim SY, Mun GH, Bang SI, Oh KS. Deep superior epigastric artery perforator ‘propeller’ flap for abdominal wall reconstruction: a case report. J Plast Reconstr Aesthet Surg 2010;63(7):1223e6. 6. Wei FC, Mardini S. Free-style free flaps. Plast Reconstr Surg 2004;114(4):910e6.
1107
7. Bravo FG, Schwarze HP. Free-style local perforator flaps: concept and classification system. J Plast Reconstr Aesthet Surg 2009;62(5):602e8. discussion 9. 8. Wallace CG, Kao HK, Jeng SF, Wei FC. Free-style flaps: a further step forward for perforator flap surgery. Plast Reconstr Surg 2009;124(Suppl. 6):e419e26. 9. Boyd JB, Taylor GI, Corlett R. The vascular territories of the superior epigastric and the deep inferior epigastric systems. Plast Reconstr Surg 1984;73(1):1e16. 10. Wong C, Saint-Cyr M, Rasko Y, Mojallal A, Bailey S, Myers S, et al. Three- and four-dimensional arterial and venous perforasomes of the internal mammary artery perforator flap. Plast Reconstr Surg 2009;124(6):1759e69.