- Email: [email protected]
The free fasciocutaneous infragluteal (FCI) flap: Outcome and patient satisfaction after 142 breast reconstructions
Accepted Manuscript The free fasciocutaneous infragluteal (FCI) flap: Outcome and patient satisfaction after 142 breast reconstructions Victoria Struckmann, M.D., Alberto Peek, M.D., Oliver Wingenbach, M.D., Leila Harhaus, M.D., Ulrich Kneser, M.D., Giesbert Holle, M.D. PII:
S1748-6815(15)00602-6
DOI:
10.1016/j.bjps.2015.12.010
Reference:
PRAS 4857
To appear in:
Journal of Plastic, Reconstructive & Aesthetic Surgery
Received Date: 14 September 2015 Revised Date:
21 December 2015
Accepted Date: 22 December 2015
Please cite this article as: Struckmann V, Peek A, Wingenbach O, Harhaus L, Kneser U, Holle G, The free fasciocutaneous infragluteal (FCI) flap: Outcome and patient satisfaction after 142 breast reconstructions, British Journal of Plastic Surgery (2016), doi: 10.1016/j.bjps.2015.12.010. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT breast reconstructions 1,2
Victoria Struckmann, M.D.
2
2
, Alberto Peek, M.D. , Oliver Wingenbach, M.D. ,
1
1
2
Leila Harhaus, M.D. , Ulrich Kneser, M.D. , Giesbert Holle, M.D. 1
BG Trauma Center Ludwigshafen
Hand and Plastic Surgery, University of Heidelberg Ludwig-Guttmann-Straße 13 67071 Ludwigshafen, Germany 2
Practice of Plastic Surgery Wingenbach, Holle & Peek
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Oeder Weg 2-4
Victoria Struckmann, M.D.
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60318 Frankfurt am Main, Germany
Corresponding author:
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Department of Hand, Plastic und Reconstructive Surgery - Burn Care Center-
Department of Hand-, Plastic and Reconstructive Surgery - Burn Care CenterUniversity of Heidelberg, BG Trauma Center Ludwigshafen Ludwig-Guttmann.Str. 13 67071 Ludwigshafen, Germany
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phone: +49-621-6810-0; fax: +49-621-6810-211
email: [email protected]
Parts of this work have been presented at the annual meeting of the German Society of Surgery, on May 2015, Munich, Germany and at the annual meeting of the German Society of Plastic, Reconstructive and Aesthetic Surgery, on October 2015, Berlin, Germany.
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The free fasciocutaneous infragluteal (FCI) flap: Outcome and patient satisfaction after 142
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ACCEPTED MANUSCRIPT Background The free fasciocutaneous infragluteal flap (FCI) is relatively rarely used for autologous breast reconstruction, however, it is a good option for thin patients. The outcome of 142 FCI flaps for breast reconstruction is presented here. Materials and Methods Between January 2008 and December 2013 142 patients received unilateral breast reconstruction
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with the FCI flap. Outcome analysis, scar quality, postoperative pain and patient satisfaction were evaluated by questionnaires and established scores. Tactile sensitivity of the breast was measured by the Semmes-Weinstein monofilament test. Results
Mean age was 45.4±9.17 (23-69) years, mean follow-up was 40.2 (12-58) months, rate of flap loss
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was 0.7% (n=1). Postoperative pain was stated with 4.2±2.5 points on the Visual Analog Scale. The quality of breast reconstruction was rated “very good” (n=43) or “good” (n=33) by 71% of patients and 89% (n=96) of patients would recommend this procedure to others. As expected, postoperative
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mobility was achieved in 80% (n=86) of patients and some obtained this even earlier. 47 patients presented for follow-up examination (44%). Scars on the reconstructed breasts were in 81% rated with 1 (n=16) or 2 (n=22) points and scars at the infragluteal donor site in 89% with 2 (n=17) or 3 (n=25) points on the Vancouver Scar Scale. Patients subjectively stated having better sensitivity of the reconstructed breast than measured objectively by monofilaments. Conclusion
The FCI-flap is a safe method for breast reconstruction due to a low percentage of flap loss and
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complications. Good patient satisfaction along with fast postoperative mobilization can be achieved. The FCI flap should be considered as a worthy alternative for autologous breast reconstruction. Keywords
Autologous breast reconstruction; fasciocutaneous infragluteal flap; free flap; patient satisfaction;
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outcome
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ACCEPTED MANUSCRIPT Introduction The free fasciocutaneous infragluteal flap (FCI) is a rarely used flap. It was inaugurated for breast reconstruction in 1998 by Christoph Papp
1
and is described as a versatile flap with a large range of
applications. Besides breast reconstruction, it has been used as coverage for achilles tendon defects and is suitable as a pedicled flap, e.g. for the closure of pressure sores of the ischial tuberosities
3
2
or
4
vaginal/ vulva reconstruction . The descending branch of the inferior gluteal artery provides the blood supply to this flap via the posterior cutaneous femoral artery. The vascular pedicle is accompanied by
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5-7
the posterior cutaneous femoral nerve, which provides the possibility of a sensory flap transfer (figure 1).
As of today there is no standardized algorithm for autologous breast reconstruction. The muscle sparing transverse rectus abdominis (MS-TRAM) and the deep inferior epigastric perforator flap 8, 9
. Especially for thin patients or after 1, 10, 11
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(DIEP) are currently the methods most frequently used
abdominal operations the free FCI flap is a safe alternative donor-region
. A second advantage
is, by medially positioning the skin island, the resulting scar almost disappears in the gluteal fold
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especially after breast reconstruction.
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loss of tactile sensation afflicts patients after breast surgery
12, 13
10
Using a neurovascular free flap could potentially provide better results regarding this aspect. Therefore the intermedius branch of the posterior cutaneous femoral nerve can be preserved and coapted to an intercostal nerve.
To date there is still a lack of outcome studies after breast reconstruction using the FCI flap. Therefore a comparison to other techniques (e.g. MS-TRAM, DIEP) is currently impossible. The aim of our study was for the first time to evaluate the outcome of the flap transfer and the
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concomitant level of patient satisfaction, after a large number of autologous breast reconstructions with the free FCI flap. In order to evaluate if the transfer of a neurovascular flap with coaptation to an intercostal nerve is worth the extra operative time, additional attention was paid to the tactile sensitivity
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of the reconstructed breasts.
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ACCEPTED MANUSCRIPT Patients and Methods The study design consisted of a retrospective part as well as a follow -up examination. We chose a study period of five years, between January 2008 and December 2013, which included all patients who received unilateral breast reconstruction with the free FCI flap in this period. Every patient with a minimum of 12 months and a maximum of 60 months postoperative follow-up time was invited after this time period to retrospectively participate in the study by filling out the survey and
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attending a follow-up examination. Study-performance is in accordance with the Helsinki Declaration for Ethical Treatment of Human Subjects and the study protocol was approved by the regional ethics committee (Frankfurt am Main, Germany, No. FF 75/2014). Written informed consent was obtained from all patients. Objective treatment data was obtained from a digital database. Age, follow-up, mean operation time, flap loss
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rate, intra- and postoperative complications and revision surgeries were evaluated. We chose the following scores and questionnaires for outcome evaluation: Satisfaction survey in accordance to Moscona et al.
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Objective aesthetical evaluation after autologous breast reconstruction is difficult. We grouped the 14
variables regarding patient satisfaction, according to Moscona et al.
, as follows: general satisfaction,
specific aspects of satisfaction, surgical outcome and effects of the operation on the spousal relationship (table 1). Results of breast sensation were classified into three subgroups: poor (range 12) satisfying (3) and normal (range 4-5) sensation. Correlation was later performed with the outcome of the Semmes-Weinstein monofilament test. Visual Analog Scale
analog scale (VAS)
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The postoperative pain during the first three days was recorded retrospectively according to the visual . 0 points reflect no pain, 10 points the worst pain imaginable.
Clinical part
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Vancouver Scar Scale
The Vancouver Scar Scale (VSS), modified by Baryza et al., was used for scar assessment
16
. It has
17-19
been used in studies worldwide for the evaluation of scar quality
. A scar of bad quality receives the
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highest score (maximum 14 points), whereas 0 points reflects the best outcome of equal to normal skin.
Semmes-Weinstein Monofilament Test The Semmes-Weinstein Monofilament Test is a non-invasive skin-sensitivity test , applicable for every part of the body
20
. We used 5 standardized monofilaments with the following sizes and contact
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pressure/mm : 2.83 (0.07g); 3.61 (0.4g); 4.31 (2g); 4.56 (4g) and 6.65 (300g). The filaments were tested (3 times each) in every quadrant of the reconstructed breast while the patients had their eyes closed. The results were correlated with breast sensitivity subjectively stated by the patients. Statistical Analysis A Statistical Package for the Social Sciences, Version 17.0 (SPSS Inc., Chicago, Illinois, USA) was used. The independence of normally distributed variables was tested by the Chi-Square-test and Fisher’s-exact-test. The Mann-Whitney-U test was used for ordinally scaled variables. The median
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21
. Statistical significance was defined
as p<0.05.
Surgical technique 1 11
The surgical technique of the FCI flap harvest has been described in detail by Papp et al.
The area
of subcutaneous fat harvesting extends further cranially, caudally, laterally, and medially underneath
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the marked donor skin, requiring very careful dissection especially in the lateral and medial direction (figure 2).
After more than 10 years of experience with this flap, we have established some variations to the original technique: Our preparation proceeds from cranial to caudal in direction of the gluteal edge. We preserve the gluteal perforators until the posterior femoral cutaneous pedicle is identified and
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perfusion of the flap has been proven. We microsurgically dissect the nerve and preserve the medial and lateral branch of the posterior cutaneous femoral nerve (see next paragraph). Neurovascular flap transfer
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The parasternal intercostal perforating nerve can be found in the second or third intercostal space, where we routinely dissect the internal mammary vessels without removing rib cartilage. However, especially in cases of previous radiotherapy, this nerve can be fibrotic and incapable of coaptation to the sensory flap nerve. If coaptation is possible it prolongs the operation time for about 20 minutes. Dissection of the sensory flap nerve is concomitant to the flap´s vascular pedicle. This posterior cutaneous femoral nerve divides proximally into three branches. The medial branch provides perineal sensation whereas the lateral branch is responsible for sensation of the posterior thigh. Both travel
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through the flap. The third, intermedius branch, goes right into the flap. The branches are always dissected microsurgically along the vascular pedicle in order to preserve the lateral and medial branches. The intermedius branch can be used for neurovascular flap transfer. Flap size
Flap size was planned preoperatively based on experience and is determined by the amount of tissue
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available in the gluteal crease and by the desired size of the breast. The surgically achieved breast sizes were satisfactory in all cases, notably in thin patients, where an equal or larger sized breast is obtainable with the FCI, as compared to the preexisting breast. Contrary to DIEP flaps, where flap size
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can easily be augmented or reduced by adding neighboring zones, this is not readily possible in FCI flap, where anatomy predetermines the flap volume. Our experience taught us that attempting to lift especially large flaps resulted in a large and conspicuous donor scar, which needs to be avoided. Due to anatomical variability, determination of flap weight or volume did not seem of any advantage to the patient and was therefore not performed.
Results 142 patients received unilateral breast reconstruction with a FCI flap between January 2008 and December 2013. We used this flap, whenever patients did not provide enough abdominal soft tissue for a DIEP-Flap operation or when former abdominal operations might have compromised potential DIEP-Flap perfusion. Additionally some patients who would have provided enough abdominal soft
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ACCEPTED MANUSCRIPT tissue did not want to have an abdominal donor site because of the abdominal scar. In the same time period (January 2008 - December 2013) we performed 265 DIEP flaps for breast reconstruction. Mean age was 45,4±9,17 (23-69) years, average follow-up time was 40,2 (range 12-58) months. Follow-up time was defined as time from surgery to study participation. Mean operative time was 316 (269-455) minutes. Ischemia time varied between 70 and 200 minutes, depending on what procedures where necessary on the chest wall. In order to reduce OR-time, it is
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our practice to first elevate the FCI flap and close the donor site. Only then the patient is turned onto her back and the necessary procedures on the breast are performed. In cases of additional
perform bilateral reconstructions with the FCI.
Retrospective part The survey was completed by 108 (76%) out of 142 patients.
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mastectomies, ischemia time has reached 200 min without any consequences. Therefore, we do not
From the analysis of the database and completed surveys, the following results have been found for
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these 108 patients: Primary breast reconstruction was performed in 35 patients (32%), 11 of these were BRCA–mutation carriers with positive family history of breast and/ or ovarial cancer and received prophylactic mastectomies. 73 women (68%) received secondary reconstruction. Out of 97 patients with diagnosed breast cancer, preoperative chemotherapy was applied in 65% (n=63), radiotherapy in 21% (n=20) and 14% (n=14) received both therapies.
Average Body Mass Index was 20.1 (min. 16.3; max. 25.6). Mean operation time was 358 (321-455) minutes. Rate of flap loss was 0,7% (n=1). Three patients had acute arterial occlusion of the arterial
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anastomosis, requiring a return to the operating room and underwent successful surgical revision during the first postoperative day. No venous problems occured (figure 3).
Figure 3: Postoperative complications
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* wound healing disorder, WHD
We classified into minor (conservative treatment) and major complications that needed operative revision. Eighteen women had minor wound healing disorders in the infragluteal area. Only two of
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them needed outpatient operative revision in local anesthesia. Minor wound healing disorders (six patients) in the reconstructed breast were treated conservatively. Donor site seroma occurred in six patients and all resolved with aspiration and wearing of pressure garments for three months. In total, 10% major complications needing operative revision occurred. Two patients complained about infragluteal neuropathy, which disappeared within six months postoperatively. Postoperative pain occurring during the first three days after surgery was stated retrospectively (at the time of survey) with 4.2±2.5 points on the VAS (figure 4). We did not divide into pain at donor site and recipient site.
Figure 4: Visual Analog Scale for postoperative pain rating
The average in-patient time was seven days (6-14d). Achieved breast sizes were satisfactory in all
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ACCEPTED MANUSCRIPT cases, especially in the thin patients, where an equal or larger sized breast is obtainable with the FCI as compared to the preexisting breast. Additional lipofilling was performed for improvement of aesthetical outcome in 7.6% (n=7) of cases, three months postoperatively at the time of nipple reconstruction. Postoperative mobility was achieved in 80% (n=86) as expected by the patient or even earlier. Good results regarding general and specific aesthetic satisfaction were achieved (table 2 and 3) and
the (sexual) relationship between the patient and the spouse (table 4).
Physical examination
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89% (n=96) of patients would repeat the procedure. The operation mostly had no relevant influence on
Forty-seven of the retrospectively invited 142 patients presented for extra follow-up examinations as
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part of the study. Scars at reconstructed breasts showed good results on the VSS (figure 5a) with a median of 2 points. Scars at infragluteal donor site were mostly rated with two (n=17) or three (n=25)
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points, the median located at 3 (figure 5b).
Figure 5a: Vancouver Scar Scale reconstructed breast Figure 5b: Vancouver Scar Scale donor site
Figure 6 a, b: 44 years old patient, three months after FCI flap for breast reconstruction on the right side, classified as Vancouver Scar Scale Score 2 (separate upload).
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Figure 7 a,b: donor site six weeks postoperatively, classified as Vancouver Scar Scale Score 4 (separate upload) A neurovascular flap transfer was performed in 44 out of the 142 patients (31%). In 18 of 47 patients (38%) who presented for follow-ups, this procedure had been performed. Concerning tactile sensitivity of reconstructed breasts, the Semmes-Weinstein monofilament test did
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not correlate to patients’ subjectively stated sensation. Of the 15 patients who stated to have normal sensation at reconstructed breast, only six were able to detect the 2g monofilament. On the other hand, 15 of the 37 women who sensed the 4g monofilament subjectively described their sensation as poor. We did not find a statistically relevant correlation (p>0,05) between coaptation of the posterior
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femoral cutaneous nerve to the intercostal nerve and results of the Semmes-Weinstein test. However 70% of patients who received nerve coaptation stated a moderate to normal sensation compared to 48% of the group without nerve reconstruction.
Discussion Presently there is no standardized algorithm for autologous breast reconstruction. Free abdominal flaps, like MS-TRAM and DIEP are currently state of the art
8, 9
. However this technique is hardly
applicable for thin patients or in cases of extensive abdominal scarring from previous (intra-) 1
abdominal surgeries, including abdominoplasties . In these cases the free FCI flap may be a save alternative donor region
1, 10, 11
7
especially due to constant anatomy of donor vessels .
Since there are very few follow-up studies after FCI flap breast reconstruction, there was a need to provide structured results and outcomes for this type of flap reconstruction, especially regarding
7
ACCEPTED MANUSCRIPT postoperative mobilization. In a future study we will compare the outcome after FCI and DIEP in our unit. Wang et al.
22
reviewed patient satisfaction and complications after MS-TRAM versus SIEA and DIEP.
MS-TRAM patients had a higher rate of abdominal hernias (4.9%) compared to DIEP patients (2.04%), and the opposite was observed for fat necrosis. There was no obvious difference with respect to the complication rate between DIEP (27.9%) and SIEA (26.7%). In a current study with 23
surgical complications after abdominally-based
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equivalent patient numbers (n=97) from Lu et al.
breast reconstruction occurred in 57.7% (n=56) with twelve cases of major complications (12%) and one flap loss. In comparison, our collective showed a slightly lower rate of major complications (10%, n=11) with three successful revisions of anastomoses, two outpatient operative revisions of donor site wound healing disorders in local anesthesia, 6 secondary aspirations of donor site seromas and one
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flap loss.
We evaluated scar quality with the Vancouver Scar Scale. Interobserver reliability of scar assessment tools are debatable. Truong et al. has in two studies proven that the internal consistency of the
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Vancouver Scar Scale is acceptable and demonstrated interobserver reliability as well as significant agreement between observer and patient ratings
24, 25
.
We identified postoperative complications by checking the database as well as asking the patients in the survey if they had experienced any complications. Thereby we had the opportunity to doublecheck complication rates. We have to admit though, that in every retrospective study especially minor complications can be lost due to a lack of documentation.
In order to increase patient compliance and willingness to participate in the study we wanted to keep
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the survey as short and simple as possible. An additional part of our study evaluated donor site morbidity of the FCI flap. This made it necessary for us to create a survey where questions concerning satisfaction regarding the infragluteal donor site were included. In the postoperative reconstruction module of the BreastQ, all questions concerning the donor site refer to the abdomen, assuming that breast reconstruction has been provided by DIEP or TRAM flap. Since we wanted to include the
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gluteal donor site, we have been looking for a short concise survey to be repurposed. Knowing, that the insertion or modifications of questions in a validated survey is scientifically incorrect, we had to design a new survey, with the disadvantage of this survey lacking validation. The survey of Moscona
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et al. covers all of the aspects we wanted to evaluate
26
Moscona et al.
14
described patient
satisfaction (n=101) after TRAM flaps for breast reconstruction without elaboration of complications. Only 67% of their patients would repeat the procedure whereas in our study 88.9% would do it again. On a five-point Likert scale
27
the overall aesthetic satisfaction was rated higher (4.09, SD 0.81) after
FCI flap reconstruction than after TRAM flap reconstruction (3.54, SD 0.89). According to Moscona et al. 80% would recommend the TRAM flap to a friend which correlates to our collective with 85%. We did not analyze the influence of immediate versus delayed reconstruction on the outcome. In our current study we did not correlate the outcome with patients’ cancer data. This would be an interesting investigation for a further study. We are aware of the relative weakness of our postoperative pain rating (VAS 4.2±2.5) due to our retrospective survey manner. However, our results correspond to postoperative pain ratings after autologous breast reconstruction in the literature. Bar-Meir et al. reported VAS around 4 on
8
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28
. Weichmann et al. used a numeric pain rating scale (also from 0-
10) one week after DIEP with 3,9 and after free TRAM with 4,3
29
.
Apart from high patient satisfaction and low complication rates, one disadvantage of the FCI flap for breast reconstruction remains: Patients need to be repositioned intraoperatively from supine to prone position, making simultaneous cooperation of two surgical teams impossible. Thus resulting in prolonged operation time compared to e.g. transverse myocutaneous gracilis (TMG) flaps. For thin 30
. However, it
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patients and in cases of previous abdominal operations, the TMG is a reliable method
often provides a limited amount of tissue, appropriate for small to medium size breasts, often requiring additional fat grafting
11, 31
. If the axillary vessels need to be used, the pedicle may display insufficient 11
length, necessitating a venous graft . Although the scar should be invisibly hidden in the inguinal area it tends to be visible in several cases
30, 32, 33
. Nevertheless even unilateral reconstruction does
34
not result in significant asymmetry of donor site . The superior gluteal artery perforator flap (SGAP), 35
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is considered to be another option for autologous breast reconstruction
. However it often lacks
pliable fat tissue and after difficult dissection only provides a short pedicle. It also requires prolonged
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operation time because of the intraoperative repositioning of the patient from prone to supine position. 34
The conspicuous scar is accompanied by gluteal asymmetry or even deformity . Unlike the inferior gluteal artery perforator flap (IGAP) the FCI flap provides the possibility to place the scar in the gluteal 10
fold (see figure 1). However the “in-the-crease” technique of harvesting the IGAP already provides improved scar appearance
36, 37
. Even with this modification of flap elevation the pedicle length is
described to be no longer than 8-11cm
36, 37
. Since the FCI pedicle is traced toward the infrapiriform 11
foramen the length can be enhanced to 18cm . 7
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Windhofer et al. have demonstrated the descending branch of the inferior gluteal artery, as the pedicle of the FCI flap, to be apparent in 91,5% of 118 cadavers. The cutaneous branch was consistently found. In cases where the descending branch was absent, the cutaneous branch originated either from medial or lateral circumflex femoral artery. In our own series, 9 cases showed the mentioned anatomic variations.
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Two patients of our early series complained about infragluteal neuropathy which disappeared within six months postoperatively. We hypothesize that in these first cases we might have irritated the lateral branch of the posterior femoral cutaneous nerve. Since some of our first patients often complained
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about this symptom, we started to spend more time on the microsurgical nerve dissection, protecting especially the lateral branch.
In order to address reduced tactile sensation in the reconstructed breasts, neurovascular FCI flaps were used whenever feasible. Due to fibrosis after radio therapy it was only performed in 18 of 47 patients who presented for the follow-up examination. The majority (70%) of women reported having satisfying or normal sensation after the nerve reconstruction procedure. However, even without nerve reconstruction, 48% reported having satisfying to normal sensation. Regarding the Semmes-Weinstein monofilament test we had to recognise, that tactile sensation reported by the patients were not reflected. We only recommend this for follow-up verification. The use of neurovascular flaps for autologous breast reconstruction is considered to be controversially. Spiegel et al.
38
performed
neurotization of 38 DIEP flaps (15 with direct coaptations and 33 with additional polyglycolic acid nerve conduits) and compared them to 9 non-neurotized DIEPs. Unfortunately it is not described in
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detail, which filament sizes of the utilized „Pressure-Specified Sensory Device“ had been used. The
35 36 37 38 39 40 41 42
1. Papp C, Windhofer C, Gruber S. Breast reconstruction with the fasciocutaneous infragluteal free flap (FCI). Ann Plast Surg 2007: 58: 131-6. 2. Papp C, Todoroff BP, Windhofer C, Gruber S. Partial and complete reconstruction of Achilles tendon defects with the fasciocutaneous infragluteal free flap. Plast Reconstr Surg 2003: 112: 777-83. 3. Windhofer C, Michlits W, Gruber S, Papp C. Reconstruction in the buttock region using the local fasciocutaneous infragluteal (FCI) flap. J Plast Reconstr Aesthet Surg 2010: 63: 126-32.
authors state that neurotization significantly increases sensory recovery of DIEP flap breast reconstructions. The use of nerve conduits provides an even better sensory recovery than direct nerve coaptation. Objectivley measured sensation was not compared to subjectively reported sensation by the patients. Blondeel et al.
39
decribed that 75% of their neurovascular DIEP flaps had protective
sensation in all examined breast segments. In comparison, only 31% of non-neurotized DIEPs showed the same results. Both authors conclude, that it is worthwhile to invest the additional operation time for 40
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38, 39
nerve coaptation to improve breast reinnervation
. However Sinis et al.
experienced the high
potential of spontaneous reinnervation in the breast area in their series. Therefore they do not
routinely perform neurovascular flaps for breast reconstruction. Additionally they describe a high incidence of neuroma formation and chronic pain syndroms after dissection and coaptation of 41, 42
. Although none of these complications
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intercostal nerves, referring to Yap et al. and Parrett et al. occurred in our collective.
Autologous tissue for breast reconstruction is considered the gold standard due to its ability to
with body weight
43
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maintain good long-term cosmetic appearance in terms of texture, consistency, ptosis, and fluctuation . However the choice of the donor site is not subject to general guidelines.
Additional multicenter, randomized controlled trials with long-term follow-up visits are necessary. In light of high satisfaction and low complication rates, the FCI flap should be considered as an equal option for autologous breast reconstruction.
Conclusion
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The free FCI flap is a safe method for breast reconstruction with low rates of flap loss and complications. Fast postoperative mobilization along with good patient satisfaction can be achieved. The FCI flap should be considered as a worthy option for autologous breast reconstruction.
Conflict of interest
None.
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Funding
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The authors have no conflict of interest to declare.
References
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4. Windhofer C, Papp C, Staudach A, Michlits W. Local fasciocutaneous infragluteal (FCI) flap for vulvar and vaginal reconstruction: a new technique in cancer surgery. Int J Gynecol Cancer 2012: 22: 132-8. 5. Scheufler O, Farhadi J, Kovach SJ, et al. Anatomical basis and clinical application of the infragluteal perforator flap. Plast Reconstr Surg 2006: 118: 1389-400. 6. Scheufler O, Farhadi J, Pierer G, Levin LS, Erdmann D. [The infragluteal perforator flap]. Handchir Mikrochir Plast Chir 2006: 38: 390-7. 7. Windhofer C, Brenner E, Moriggl B, Papp C. Relationship between the descending branch of the inferior gluteal artery and the posterior femoral cutaneous nerve applicable to flap surgery. Surg Radiol Anat 2002: 24: 253-7. 8. Hartrampf CR, Scheflan M, Black PW. Breast reconstruction with a transverse abdominal island flap. Plast Reconstr Surg 1982: 69: 216-25. 9. Allen RJ, Treece P. Deep inferior epigastric perforator flap for breast reconstruction. Ann Plast Surg 1994: 32: 32-8. 10. Papp C, Wechselberger G, Schoeller T. Autologous breast reconstruction after breast-conserving cancer surgery. Plast Reconstr Surg 1998: 102: 1932-6; discussion 37-8. 11. Papp C, Windhofer C, Michlits W. Autologous breast augmentation with the deepithelialized fasciocutaneous infragluteal free flap: a 10-year experience. Ann Plast Surg 2011: 66: 587-92. 12. Hamdi M, Greuse M, De Mey A, Webster MH. A prospective quantitative comparison of breast sensation after superior and inferior pedicle mammaplasty. Br J Plast Surg 2001: 54: 39-42. 13. Schlenz I, Rigel S, Schemper M, Kuzbari R. Alteration of nipple and areola sensitivity by reduction mammaplasty: a prospective comparison of five techniques. Plast Reconstr Surg 2005: 115: 743-51; discussion 52-4. 14. Moscona RA, Holander L, Or D, Fodor L. Patient satisfaction and aesthetic results after pedicled transverse rectus abdominis muscle flap for breast reconstruction. Ann Surg Oncol 2006: 13: 1739-46. 15. Bodian CA, Freedman G, Hossain S, Eisenkraft JB, Beilin Y. The visual analog scale for pain: clinical significance in postoperative patients. Anesthesiology 2001: 95: 1356-61. 16. Baryza MJ, Baryza GA. The Vancouver Scar Scale: an administration tool and its interrater reliability. J Burn Care Rehabil 1995: 16: 535-8. 17. Aird LN, Bristol SG, Phang PT, Raval MJ, Brown CJ. Randomized double-blind trial comparing the cosmetic outcome of cutting diathermy versus scalpel for skin incisions. Br J Surg 2015: 102: 489-94. 18. Braam KI, Kooijmans EC, van Dulmen-den Broeder E, et al. No efficacy for silicone gel sheeting in prevention of abnormal scar formation in children with cancer: a randomized controlled trial. Plast Reconstr Surg 2015: 135: 1086-94. 19. Sood R, Roggy DE, Zieger MJ, et al. A comparative study of spray keratinocytes and autologous meshed split-thickness skin graft in the treatment of acute burn injuries. Wounds 2015: 27: 31-40. 20. Weinstein S. Fifty years of somatosensory research: from the Semmes-Weinstein monofilaments to the Weinstein Enhanced Sensory Test. J Hand Ther 1993: 6: 1122; discussion 50. 21. Januszyk M, Gurtner GC. Statistics in medicine. Plast Reconstr Surg 2011: 127: 437-44. 22. Wang XL, Liu LB, Song FM, Wang QY. Meta-analysis of the safety and factors contributing to complications of MS-TRAM, DIEP, and SIEA flaps for breast reconstruction. Aesthetic Plast Surg 2014: 38: 681-91.
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23. Lu SM, Nelson JA, Fischer JP, et al. The impact of complications on function, health, and satisfaction following abdominally based autologous breast reconstruction: a prospective evaluation. J Plast Reconstr Aesthet Surg 2014: 67: 682-92. 24. Truong PT, Lee JC, Soer B, Gaul CA, Olivotto IA. Reliability and validity testing of the Patient and Observer Scar Assessment Scale in evaluating linear scars after breast cancer surgery. Plast Reconstr Surg 2007: 119: 487-94. 25. Truong PT, Abnousi F, Yong CM, et al. Standardized assessment of breast cancer surgical scars integrating the Vancouver Scar Scale, Short-Form McGill Pain Questionnaire, and patients' perspectives. Plast Reconstr Surg 2005: 116: 1291-9. 26. Ludolph I, Horch RE, Harlander M, et al. Is there a Rationale for Autologous Breast Reconstruction in Older Patients? A Retrospective Single Center Analysis of Quality of life, Complications and Comorbidities after DIEP or ms-TRAM Flap Using the BREAST-Q. Breast J 2015: 21: 588-95. 27. Donabedian A. Evaluating the quality of medical care. Milbank Mem Fund Q 1966: 44: Suppl:166-206. 28. Bar-Meir ED, Yueh JH, Hess PE, et al. Postoperative Pain Management in DIEP Flap Breast Reconstruction: Identification of Patients With Poor Pain Control. Eplasty 2010: 10. 29. Weichman KE, Hamill JB, Kim HM, et al. Understanding the recovery phase of breast reconstructions: Patient-reported outcomes correlated to the type and timing of reconstruction. J Plast Reconstr Aesthet Surg 2015: 68: 1370-8. 30. Fansa H, Schirmer S, Warnecke IC, Cervelli A, Frerichs O. The transverse myocutaneous gracilis muscle flap: a fast and reliable method for breast reconstruction. Plast Reconstr Surg 2008: 122: 1326-33. 31. Craggs B, Vanmierlo B, Zeltzer A, et al. Donor-site morbidity following harvest of the transverse myocutaneous gracilis flap for breast reconstruction. Plast Reconstr Surg 2014: 134: 682e-91e. 32. Deutinger M, Kuzbari R, Paternostro-Sluga T, et al. Donor-site morbidity of the gracilis flap. Plast Reconstr Surg 1995: 95: 1240-4. 33. Pulzl P, Schoeller T, Kleewein K, Wechselberger G. Donor-site morbidity of the transverse musculocutaneous gracilis flap in autologous breast reconstruction: shortterm and long-term results. Plast Reconstr Surg 2011: 128: 233e-42e. 34. Wechselberger G, Schoeller T. The transverse myocutaneous gracilis free flap: a valuable tissue source in autologous breast reconstruction. Plast Reconstr Surg 2004: 114: 69-73. 35. Fujino T, Harasina T, Aoyagi F. Reconstruction for aplasia of the breast and pectoral region by microvascular transfer of a free flap from the buttock. Plast Reconstr Surg 1975: 56: 178-81. 36. Allen RJ, Levine JL, Granzow JW. The in-the-crease inferior gluteal artery perforator flap for breast reconstruction. Plast Reconstr Surg 2006: 118: 333-9. 37. Levine JL, Miller Q, Vasile J, et al. Simultaneous bilateral breast reconstruction with in-the-crease inferior gluteal artery perforator flaps. Ann Plast Surg 2009: 63: 249-54. 38. Spiegel AJ, Menn ZK, Eldor L, Kaufman Y, Dellon AL. Breast Reinnervation: DIEP Neurotization Using the Third Anterior Intercostal Nerve. Plast Reconstr Surg Glob Open 2013: 1: e72. 39. Blondeel PN, Demuynck M, Mete D, et al. Sensory nerve repair in perforator flaps for autologous breast reconstruction: sensational or senseless? Br J Plast Surg 1999: 52: 37-44.
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ACCEPTED MANUSCRIPT 40. Sinis N, Lamia A, Gudrun H, Schoeller T, Werdin F. Sensory reinnervation of free flaps in reconstruction of the breast and the upper and lower extremities. Neural Regen Res 2012: 7: 2279-85. 41. Parrett BM, Caterson SA, Tobias AM, Lee BT. The rib-sparing technique for internal mammary vessel exposure in microsurgical breast reconstruction. Ann Plast Surg 2008: 60: 241-3. 42. Yap LH, Whiten SC, Forster A, Stevenson HJ. Sensory recovery in the sensate free transverse rectus abdominis myocutaneous flap. Plast Reconstr Surg 2005: 115: 1280-8. 43. Clough KB, O'Donoghue JM, Fitoussi AD, Vlastos G, Falcou MC. Prospective evaluation of late cosmetic results following breast reconstruction: II. Tram flap reconstruction. Plast Reconstr Surg 2001: 107: 1710-6.
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ACCEPTED MANUSCRIPT Figure 1: Anatomy of FCI Flap
Figure 2: surgical markings FCI Flap
Figure 3: Postoperative complications during in-patient time •
wound healing disorder, WHD
Figure 4: Visual Analog Scale for postoperative pain rating
Figure 5a: Vancouver Scar Scale reconstructed breast
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Figure 5b: Vancouver Scar Scale donor site
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•
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Figure 6a, b: 44 years old patient, three months after fci flap for breast reconstruction on the right side, classified as Vancouver Scar Scale Score 2 (separate upload).
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Figure 7 a, b: donor site six weeks postoperatively, classified as Vancouver Scar Scale Score 4 (separate upload)
ACCEPTED MANUSCRIPT Table 1: Investigated parameters of satisfaction survey Type of variable
Change in sexual intercourse
I (low) to 5 (high) Yes/ no Yes/ no
Categorical, dichotomous Categorical, dichotomous Numerical Numerical Numerical
Yes/ no Yes/ no I (non) to 5 (normal) I (non) to 5 (normal) I (very) to 5 (not at all)
Numerical Numerical Numerical Numerical Numerical
I (no) to 5 (yes) I (low) to 5 (high) I (low) to 5 (high) I (low) to 5 (high) I (low) to 5 (high)
Numerical Numerical
Numerical
Change in woman’s attitude to spouse
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Numerical
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Sexual relationship with spouse
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Numerical Categorical, dichotomous Categorical, dichotomous
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General satisfaction Satisfaction with outcome Would you repeat the procedure Recommend to a friend Specific aspects of satisfaction and surgical outcome Everyday difficulty Difficulty in strenuous exercise Touch sensation breast Touch sensation infragluteal Disturbance from infragluteal scar Aesthetic aspects Symmetry of breasts Satisfaction with breast scars Satisfaction with appearance in clothes Satisfaction with nude appearance Aesthetic satisfaction Effect of procedure on relationship with spouse Satisfaction of spouse with procedure Change in attraction of spouse
Range
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Variable
I (no) to 5 (yes) I (worse), 2 (no change), 3 (better) I (worse), 2 (no change), 3 (better) I (worse), 2 (no change), 3 (better) I (worse), 2 (no change), 3 (better)
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Range 1 (low) to 5 (high) Yes/ no Yes/ no
4.0 Yes 88.9%; No 11.1% Yes 85.2%; No 14.8%
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Satisfaction with outcome Would you repeat the procedure Recommend to a friend
Median
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Range 1 (no) to 5 (Yes) 1 (low) to 5 (high) 1 (low) to 5 (high) 1 (low) to 5 (high) 1 (low) to 5 (high)
4.0 4.0 5.0 4.0 4.0
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Symmetry of breasts Satisfaction with breast scars Satisfaction with clothed appearance Satisfaction with nude appearance Aesthetic satisfaction
Median
ACCEPTED MANUSCRIPT Table 4: Results of effects of procedure on relationship with spouse Variable
Range
Satisfaction of spouse with procedure Change in attraction of spouse Change in sexual intercourse Change in woman`s attitude to spouse
I (no) to 5 (Yes) I (worse), 2 (no change), 3 (better) I (worse), 2 (no change), 3 (better) I (worse), 2 (no change), 3 (better) I (worse), 2 (no change), 3 (better)
4.0 2.0 2.0 2.0 2.0
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Sexual relationship with spouse
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2
cardiovascular
2
revisions of anastomosis
3
seroma infragluteal
6
WHD* breast
6
haematoma breast
6
WHD* infragluteal
17 20 40 60 80 Number of patients (n=108)
100
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neuropathy infragluteal
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complications in % of n=108
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average 4.2± 2.5
20
17 15
15
13 11
10
10 6 5
4
3
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Number of patients (n=108)
30
3
1
0 1
2
3
4 5 6 Visual Analog Scale
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Figure 2: Visual Analog Scale for postoperative pain rating
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0 0 0 0 0 0 0 0 0 0
0 = normal skin 14 = worst scar quality
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16 1 5
10 15 Number of patients (n=47)
20
25
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Vancouver Scar Scale
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3
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Vancouver Scar Scale (VSS)
Figure 3a: Vancouver Scar Scale reconstructed breast
25 17
2
0
0
5
10 15 Number of patients (n=47)
Figure 3b: Vancouver Scar Scale donor site
20
25
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S1748-6815(15)00602-6
DOI:
10.1016/j.bjps.2015.12.010
Reference:
PRAS 4857
To appear in:
Journal of Plastic, Reconstructive & Aesthetic Surgery
Received Date: 14 September 2015 Revised Date:
21 December 2015
Accepted Date: 22 December 2015
Please cite this article as: Struckmann V, Peek A, Wingenbach O, Harhaus L, Kneser U, Holle G, The free fasciocutaneous infragluteal (FCI) flap: Outcome and patient satisfaction after 142 breast reconstructions, British Journal of Plastic Surgery (2016), doi: 10.1016/j.bjps.2015.12.010. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT breast reconstructions 1,2
Victoria Struckmann, M.D.
2
2
, Alberto Peek, M.D. , Oliver Wingenbach, M.D. ,
1
1
2
Leila Harhaus, M.D. , Ulrich Kneser, M.D. , Giesbert Holle, M.D. 1
BG Trauma Center Ludwigshafen
Hand and Plastic Surgery, University of Heidelberg Ludwig-Guttmann-Straße 13 67071 Ludwigshafen, Germany 2
Practice of Plastic Surgery Wingenbach, Holle & Peek
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Oeder Weg 2-4
Victoria Struckmann, M.D.
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60318 Frankfurt am Main, Germany
Corresponding author:
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Department of Hand, Plastic und Reconstructive Surgery - Burn Care Center-
Department of Hand-, Plastic and Reconstructive Surgery - Burn Care CenterUniversity of Heidelberg, BG Trauma Center Ludwigshafen Ludwig-Guttmann.Str. 13 67071 Ludwigshafen, Germany
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phone: +49-621-6810-0; fax: +49-621-6810-211
email: [email protected]
Parts of this work have been presented at the annual meeting of the German Society of Surgery, on May 2015, Munich, Germany and at the annual meeting of the German Society of Plastic, Reconstructive and Aesthetic Surgery, on October 2015, Berlin, Germany.
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The free fasciocutaneous infragluteal (FCI) flap: Outcome and patient satisfaction after 142
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ACCEPTED MANUSCRIPT Background The free fasciocutaneous infragluteal flap (FCI) is relatively rarely used for autologous breast reconstruction, however, it is a good option for thin patients. The outcome of 142 FCI flaps for breast reconstruction is presented here. Materials and Methods Between January 2008 and December 2013 142 patients received unilateral breast reconstruction
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with the FCI flap. Outcome analysis, scar quality, postoperative pain and patient satisfaction were evaluated by questionnaires and established scores. Tactile sensitivity of the breast was measured by the Semmes-Weinstein monofilament test. Results
Mean age was 45.4±9.17 (23-69) years, mean follow-up was 40.2 (12-58) months, rate of flap loss
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was 0.7% (n=1). Postoperative pain was stated with 4.2±2.5 points on the Visual Analog Scale. The quality of breast reconstruction was rated “very good” (n=43) or “good” (n=33) by 71% of patients and 89% (n=96) of patients would recommend this procedure to others. As expected, postoperative
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mobility was achieved in 80% (n=86) of patients and some obtained this even earlier. 47 patients presented for follow-up examination (44%). Scars on the reconstructed breasts were in 81% rated with 1 (n=16) or 2 (n=22) points and scars at the infragluteal donor site in 89% with 2 (n=17) or 3 (n=25) points on the Vancouver Scar Scale. Patients subjectively stated having better sensitivity of the reconstructed breast than measured objectively by monofilaments. Conclusion
The FCI-flap is a safe method for breast reconstruction due to a low percentage of flap loss and
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complications. Good patient satisfaction along with fast postoperative mobilization can be achieved. The FCI flap should be considered as a worthy alternative for autologous breast reconstruction. Keywords
Autologous breast reconstruction; fasciocutaneous infragluteal flap; free flap; patient satisfaction;
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ACCEPTED MANUSCRIPT Introduction The free fasciocutaneous infragluteal flap (FCI) is a rarely used flap. It was inaugurated for breast reconstruction in 1998 by Christoph Papp
1
and is described as a versatile flap with a large range of
applications. Besides breast reconstruction, it has been used as coverage for achilles tendon defects and is suitable as a pedicled flap, e.g. for the closure of pressure sores of the ischial tuberosities
3
2
or
4
vaginal/ vulva reconstruction . The descending branch of the inferior gluteal artery provides the blood supply to this flap via the posterior cutaneous femoral artery. The vascular pedicle is accompanied by
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5-7
the posterior cutaneous femoral nerve, which provides the possibility of a sensory flap transfer (figure 1).
As of today there is no standardized algorithm for autologous breast reconstruction. The muscle sparing transverse rectus abdominis (MS-TRAM) and the deep inferior epigastric perforator flap 8, 9
. Especially for thin patients or after 1, 10, 11
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(DIEP) are currently the methods most frequently used
abdominal operations the free FCI flap is a safe alternative donor-region
. A second advantage
is, by medially positioning the skin island, the resulting scar almost disappears in the gluteal fold
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especially after breast reconstruction.
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loss of tactile sensation afflicts patients after breast surgery
12, 13
10
Using a neurovascular free flap could potentially provide better results regarding this aspect. Therefore the intermedius branch of the posterior cutaneous femoral nerve can be preserved and coapted to an intercostal nerve.
To date there is still a lack of outcome studies after breast reconstruction using the FCI flap. Therefore a comparison to other techniques (e.g. MS-TRAM, DIEP) is currently impossible. The aim of our study was for the first time to evaluate the outcome of the flap transfer and the
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concomitant level of patient satisfaction, after a large number of autologous breast reconstructions with the free FCI flap. In order to evaluate if the transfer of a neurovascular flap with coaptation to an intercostal nerve is worth the extra operative time, additional attention was paid to the tactile sensitivity
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of the reconstructed breasts.
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ACCEPTED MANUSCRIPT Patients and Methods The study design consisted of a retrospective part as well as a follow -up examination. We chose a study period of five years, between January 2008 and December 2013, which included all patients who received unilateral breast reconstruction with the free FCI flap in this period. Every patient with a minimum of 12 months and a maximum of 60 months postoperative follow-up time was invited after this time period to retrospectively participate in the study by filling out the survey and
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attending a follow-up examination. Study-performance is in accordance with the Helsinki Declaration for Ethical Treatment of Human Subjects and the study protocol was approved by the regional ethics committee (Frankfurt am Main, Germany, No. FF 75/2014). Written informed consent was obtained from all patients. Objective treatment data was obtained from a digital database. Age, follow-up, mean operation time, flap loss
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rate, intra- and postoperative complications and revision surgeries were evaluated. We chose the following scores and questionnaires for outcome evaluation: Satisfaction survey in accordance to Moscona et al.
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Objective aesthetical evaluation after autologous breast reconstruction is difficult. We grouped the 14
variables regarding patient satisfaction, according to Moscona et al.
, as follows: general satisfaction,
specific aspects of satisfaction, surgical outcome and effects of the operation on the spousal relationship (table 1). Results of breast sensation were classified into three subgroups: poor (range 12) satisfying (3) and normal (range 4-5) sensation. Correlation was later performed with the outcome of the Semmes-Weinstein monofilament test. Visual Analog Scale
analog scale (VAS)
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The postoperative pain during the first three days was recorded retrospectively according to the visual . 0 points reflect no pain, 10 points the worst pain imaginable.
Clinical part
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Vancouver Scar Scale
The Vancouver Scar Scale (VSS), modified by Baryza et al., was used for scar assessment
16
. It has
17-19
been used in studies worldwide for the evaluation of scar quality
. A scar of bad quality receives the
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highest score (maximum 14 points), whereas 0 points reflects the best outcome of equal to normal skin.
Semmes-Weinstein Monofilament Test The Semmes-Weinstein Monofilament Test is a non-invasive skin-sensitivity test , applicable for every part of the body
20
. We used 5 standardized monofilaments with the following sizes and contact
2
pressure/mm : 2.83 (0.07g); 3.61 (0.4g); 4.31 (2g); 4.56 (4g) and 6.65 (300g). The filaments were tested (3 times each) in every quadrant of the reconstructed breast while the patients had their eyes closed. The results were correlated with breast sensitivity subjectively stated by the patients. Statistical Analysis A Statistical Package for the Social Sciences, Version 17.0 (SPSS Inc., Chicago, Illinois, USA) was used. The independence of normally distributed variables was tested by the Chi-Square-test and Fisher’s-exact-test. The Mann-Whitney-U test was used for ordinally scaled variables. The median
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21
. Statistical significance was defined
as p<0.05.
Surgical technique 1 11
The surgical technique of the FCI flap harvest has been described in detail by Papp et al.
The area
of subcutaneous fat harvesting extends further cranially, caudally, laterally, and medially underneath
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the marked donor skin, requiring very careful dissection especially in the lateral and medial direction (figure 2).
After more than 10 years of experience with this flap, we have established some variations to the original technique: Our preparation proceeds from cranial to caudal in direction of the gluteal edge. We preserve the gluteal perforators until the posterior femoral cutaneous pedicle is identified and
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perfusion of the flap has been proven. We microsurgically dissect the nerve and preserve the medial and lateral branch of the posterior cutaneous femoral nerve (see next paragraph). Neurovascular flap transfer
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The parasternal intercostal perforating nerve can be found in the second or third intercostal space, where we routinely dissect the internal mammary vessels without removing rib cartilage. However, especially in cases of previous radiotherapy, this nerve can be fibrotic and incapable of coaptation to the sensory flap nerve. If coaptation is possible it prolongs the operation time for about 20 minutes. Dissection of the sensory flap nerve is concomitant to the flap´s vascular pedicle. This posterior cutaneous femoral nerve divides proximally into three branches. The medial branch provides perineal sensation whereas the lateral branch is responsible for sensation of the posterior thigh. Both travel
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through the flap. The third, intermedius branch, goes right into the flap. The branches are always dissected microsurgically along the vascular pedicle in order to preserve the lateral and medial branches. The intermedius branch can be used for neurovascular flap transfer. Flap size
Flap size was planned preoperatively based on experience and is determined by the amount of tissue
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available in the gluteal crease and by the desired size of the breast. The surgically achieved breast sizes were satisfactory in all cases, notably in thin patients, where an equal or larger sized breast is obtainable with the FCI, as compared to the preexisting breast. Contrary to DIEP flaps, where flap size
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can easily be augmented or reduced by adding neighboring zones, this is not readily possible in FCI flap, where anatomy predetermines the flap volume. Our experience taught us that attempting to lift especially large flaps resulted in a large and conspicuous donor scar, which needs to be avoided. Due to anatomical variability, determination of flap weight or volume did not seem of any advantage to the patient and was therefore not performed.
Results 142 patients received unilateral breast reconstruction with a FCI flap between January 2008 and December 2013. We used this flap, whenever patients did not provide enough abdominal soft tissue for a DIEP-Flap operation or when former abdominal operations might have compromised potential DIEP-Flap perfusion. Additionally some patients who would have provided enough abdominal soft
5
ACCEPTED MANUSCRIPT tissue did not want to have an abdominal donor site because of the abdominal scar. In the same time period (January 2008 - December 2013) we performed 265 DIEP flaps for breast reconstruction. Mean age was 45,4±9,17 (23-69) years, average follow-up time was 40,2 (range 12-58) months. Follow-up time was defined as time from surgery to study participation. Mean operative time was 316 (269-455) minutes. Ischemia time varied between 70 and 200 minutes, depending on what procedures where necessary on the chest wall. In order to reduce OR-time, it is
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our practice to first elevate the FCI flap and close the donor site. Only then the patient is turned onto her back and the necessary procedures on the breast are performed. In cases of additional
perform bilateral reconstructions with the FCI.
Retrospective part The survey was completed by 108 (76%) out of 142 patients.
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mastectomies, ischemia time has reached 200 min without any consequences. Therefore, we do not
From the analysis of the database and completed surveys, the following results have been found for
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these 108 patients: Primary breast reconstruction was performed in 35 patients (32%), 11 of these were BRCA–mutation carriers with positive family history of breast and/ or ovarial cancer and received prophylactic mastectomies. 73 women (68%) received secondary reconstruction. Out of 97 patients with diagnosed breast cancer, preoperative chemotherapy was applied in 65% (n=63), radiotherapy in 21% (n=20) and 14% (n=14) received both therapies.
Average Body Mass Index was 20.1 (min. 16.3; max. 25.6). Mean operation time was 358 (321-455) minutes. Rate of flap loss was 0,7% (n=1). Three patients had acute arterial occlusion of the arterial
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anastomosis, requiring a return to the operating room and underwent successful surgical revision during the first postoperative day. No venous problems occured (figure 3).
Figure 3: Postoperative complications
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* wound healing disorder, WHD
We classified into minor (conservative treatment) and major complications that needed operative revision. Eighteen women had minor wound healing disorders in the infragluteal area. Only two of
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them needed outpatient operative revision in local anesthesia. Minor wound healing disorders (six patients) in the reconstructed breast were treated conservatively. Donor site seroma occurred in six patients and all resolved with aspiration and wearing of pressure garments for three months. In total, 10% major complications needing operative revision occurred. Two patients complained about infragluteal neuropathy, which disappeared within six months postoperatively. Postoperative pain occurring during the first three days after surgery was stated retrospectively (at the time of survey) with 4.2±2.5 points on the VAS (figure 4). We did not divide into pain at donor site and recipient site.
Figure 4: Visual Analog Scale for postoperative pain rating
The average in-patient time was seven days (6-14d). Achieved breast sizes were satisfactory in all
6
ACCEPTED MANUSCRIPT cases, especially in the thin patients, where an equal or larger sized breast is obtainable with the FCI as compared to the preexisting breast. Additional lipofilling was performed for improvement of aesthetical outcome in 7.6% (n=7) of cases, three months postoperatively at the time of nipple reconstruction. Postoperative mobility was achieved in 80% (n=86) as expected by the patient or even earlier. Good results regarding general and specific aesthetic satisfaction were achieved (table 2 and 3) and
the (sexual) relationship between the patient and the spouse (table 4).
Physical examination
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89% (n=96) of patients would repeat the procedure. The operation mostly had no relevant influence on
Forty-seven of the retrospectively invited 142 patients presented for extra follow-up examinations as
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part of the study. Scars at reconstructed breasts showed good results on the VSS (figure 5a) with a median of 2 points. Scars at infragluteal donor site were mostly rated with two (n=17) or three (n=25)
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points, the median located at 3 (figure 5b).
Figure 5a: Vancouver Scar Scale reconstructed breast Figure 5b: Vancouver Scar Scale donor site
Figure 6 a, b: 44 years old patient, three months after FCI flap for breast reconstruction on the right side, classified as Vancouver Scar Scale Score 2 (separate upload).
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Figure 7 a,b: donor site six weeks postoperatively, classified as Vancouver Scar Scale Score 4 (separate upload) A neurovascular flap transfer was performed in 44 out of the 142 patients (31%). In 18 of 47 patients (38%) who presented for follow-ups, this procedure had been performed. Concerning tactile sensitivity of reconstructed breasts, the Semmes-Weinstein monofilament test did
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not correlate to patients’ subjectively stated sensation. Of the 15 patients who stated to have normal sensation at reconstructed breast, only six were able to detect the 2g monofilament. On the other hand, 15 of the 37 women who sensed the 4g monofilament subjectively described their sensation as poor. We did not find a statistically relevant correlation (p>0,05) between coaptation of the posterior
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femoral cutaneous nerve to the intercostal nerve and results of the Semmes-Weinstein test. However 70% of patients who received nerve coaptation stated a moderate to normal sensation compared to 48% of the group without nerve reconstruction.
Discussion Presently there is no standardized algorithm for autologous breast reconstruction. Free abdominal flaps, like MS-TRAM and DIEP are currently state of the art
8, 9
. However this technique is hardly
applicable for thin patients or in cases of extensive abdominal scarring from previous (intra-) 1
abdominal surgeries, including abdominoplasties . In these cases the free FCI flap may be a save alternative donor region
1, 10, 11
7
especially due to constant anatomy of donor vessels .
Since there are very few follow-up studies after FCI flap breast reconstruction, there was a need to provide structured results and outcomes for this type of flap reconstruction, especially regarding
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22
reviewed patient satisfaction and complications after MS-TRAM versus SIEA and DIEP.
MS-TRAM patients had a higher rate of abdominal hernias (4.9%) compared to DIEP patients (2.04%), and the opposite was observed for fat necrosis. There was no obvious difference with respect to the complication rate between DIEP (27.9%) and SIEA (26.7%). In a current study with 23
surgical complications after abdominally-based
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equivalent patient numbers (n=97) from Lu et al.
breast reconstruction occurred in 57.7% (n=56) with twelve cases of major complications (12%) and one flap loss. In comparison, our collective showed a slightly lower rate of major complications (10%, n=11) with three successful revisions of anastomoses, two outpatient operative revisions of donor site wound healing disorders in local anesthesia, 6 secondary aspirations of donor site seromas and one
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flap loss.
We evaluated scar quality with the Vancouver Scar Scale. Interobserver reliability of scar assessment tools are debatable. Truong et al. has in two studies proven that the internal consistency of the
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Vancouver Scar Scale is acceptable and demonstrated interobserver reliability as well as significant agreement between observer and patient ratings
24, 25
.
We identified postoperative complications by checking the database as well as asking the patients in the survey if they had experienced any complications. Thereby we had the opportunity to doublecheck complication rates. We have to admit though, that in every retrospective study especially minor complications can be lost due to a lack of documentation.
In order to increase patient compliance and willingness to participate in the study we wanted to keep
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the survey as short and simple as possible. An additional part of our study evaluated donor site morbidity of the FCI flap. This made it necessary for us to create a survey where questions concerning satisfaction regarding the infragluteal donor site were included. In the postoperative reconstruction module of the BreastQ, all questions concerning the donor site refer to the abdomen, assuming that breast reconstruction has been provided by DIEP or TRAM flap. Since we wanted to include the
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gluteal donor site, we have been looking for a short concise survey to be repurposed. Knowing, that the insertion or modifications of questions in a validated survey is scientifically incorrect, we had to design a new survey, with the disadvantage of this survey lacking validation. The survey of Moscona
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et al. covers all of the aspects we wanted to evaluate
26
Moscona et al.
14
described patient
satisfaction (n=101) after TRAM flaps for breast reconstruction without elaboration of complications. Only 67% of their patients would repeat the procedure whereas in our study 88.9% would do it again. On a five-point Likert scale
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the overall aesthetic satisfaction was rated higher (4.09, SD 0.81) after
FCI flap reconstruction than after TRAM flap reconstruction (3.54, SD 0.89). According to Moscona et al. 80% would recommend the TRAM flap to a friend which correlates to our collective with 85%. We did not analyze the influence of immediate versus delayed reconstruction on the outcome. In our current study we did not correlate the outcome with patients’ cancer data. This would be an interesting investigation for a further study. We are aware of the relative weakness of our postoperative pain rating (VAS 4.2±2.5) due to our retrospective survey manner. However, our results correspond to postoperative pain ratings after autologous breast reconstruction in the literature. Bar-Meir et al. reported VAS around 4 on
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28
. Weichmann et al. used a numeric pain rating scale (also from 0-
10) one week after DIEP with 3,9 and after free TRAM with 4,3
29
.
Apart from high patient satisfaction and low complication rates, one disadvantage of the FCI flap for breast reconstruction remains: Patients need to be repositioned intraoperatively from supine to prone position, making simultaneous cooperation of two surgical teams impossible. Thus resulting in prolonged operation time compared to e.g. transverse myocutaneous gracilis (TMG) flaps. For thin 30
. However, it
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patients and in cases of previous abdominal operations, the TMG is a reliable method
often provides a limited amount of tissue, appropriate for small to medium size breasts, often requiring additional fat grafting
11, 31
. If the axillary vessels need to be used, the pedicle may display insufficient 11
length, necessitating a venous graft . Although the scar should be invisibly hidden in the inguinal area it tends to be visible in several cases
30, 32, 33
. Nevertheless even unilateral reconstruction does
34
not result in significant asymmetry of donor site . The superior gluteal artery perforator flap (SGAP), 35
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is considered to be another option for autologous breast reconstruction
. However it often lacks
pliable fat tissue and after difficult dissection only provides a short pedicle. It also requires prolonged
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operation time because of the intraoperative repositioning of the patient from prone to supine position. 34
The conspicuous scar is accompanied by gluteal asymmetry or even deformity . Unlike the inferior gluteal artery perforator flap (IGAP) the FCI flap provides the possibility to place the scar in the gluteal 10
fold (see figure 1). However the “in-the-crease” technique of harvesting the IGAP already provides improved scar appearance
36, 37
. Even with this modification of flap elevation the pedicle length is
described to be no longer than 8-11cm
36, 37
. Since the FCI pedicle is traced toward the infrapiriform 11
foramen the length can be enhanced to 18cm . 7
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Windhofer et al. have demonstrated the descending branch of the inferior gluteal artery, as the pedicle of the FCI flap, to be apparent in 91,5% of 118 cadavers. The cutaneous branch was consistently found. In cases where the descending branch was absent, the cutaneous branch originated either from medial or lateral circumflex femoral artery. In our own series, 9 cases showed the mentioned anatomic variations.
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Two patients of our early series complained about infragluteal neuropathy which disappeared within six months postoperatively. We hypothesize that in these first cases we might have irritated the lateral branch of the posterior femoral cutaneous nerve. Since some of our first patients often complained
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about this symptom, we started to spend more time on the microsurgical nerve dissection, protecting especially the lateral branch.
In order to address reduced tactile sensation in the reconstructed breasts, neurovascular FCI flaps were used whenever feasible. Due to fibrosis after radio therapy it was only performed in 18 of 47 patients who presented for the follow-up examination. The majority (70%) of women reported having satisfying or normal sensation after the nerve reconstruction procedure. However, even without nerve reconstruction, 48% reported having satisfying to normal sensation. Regarding the Semmes-Weinstein monofilament test we had to recognise, that tactile sensation reported by the patients were not reflected. We only recommend this for follow-up verification. The use of neurovascular flaps for autologous breast reconstruction is considered to be controversially. Spiegel et al.
38
performed
neurotization of 38 DIEP flaps (15 with direct coaptations and 33 with additional polyglycolic acid nerve conduits) and compared them to 9 non-neurotized DIEPs. Unfortunately it is not described in
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detail, which filament sizes of the utilized „Pressure-Specified Sensory Device“ had been used. The
35 36 37 38 39 40 41 42
1. Papp C, Windhofer C, Gruber S. Breast reconstruction with the fasciocutaneous infragluteal free flap (FCI). Ann Plast Surg 2007: 58: 131-6. 2. Papp C, Todoroff BP, Windhofer C, Gruber S. Partial and complete reconstruction of Achilles tendon defects with the fasciocutaneous infragluteal free flap. Plast Reconstr Surg 2003: 112: 777-83. 3. Windhofer C, Michlits W, Gruber S, Papp C. Reconstruction in the buttock region using the local fasciocutaneous infragluteal (FCI) flap. J Plast Reconstr Aesthet Surg 2010: 63: 126-32.
authors state that neurotization significantly increases sensory recovery of DIEP flap breast reconstructions. The use of nerve conduits provides an even better sensory recovery than direct nerve coaptation. Objectivley measured sensation was not compared to subjectively reported sensation by the patients. Blondeel et al.
39
decribed that 75% of their neurovascular DIEP flaps had protective
sensation in all examined breast segments. In comparison, only 31% of non-neurotized DIEPs showed the same results. Both authors conclude, that it is worthwhile to invest the additional operation time for 40
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38, 39
nerve coaptation to improve breast reinnervation
. However Sinis et al.
experienced the high
potential of spontaneous reinnervation in the breast area in their series. Therefore they do not
routinely perform neurovascular flaps for breast reconstruction. Additionally they describe a high incidence of neuroma formation and chronic pain syndroms after dissection and coaptation of 41, 42
. Although none of these complications
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intercostal nerves, referring to Yap et al. and Parrett et al. occurred in our collective.
Autologous tissue for breast reconstruction is considered the gold standard due to its ability to
with body weight
43
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maintain good long-term cosmetic appearance in terms of texture, consistency, ptosis, and fluctuation . However the choice of the donor site is not subject to general guidelines.
Additional multicenter, randomized controlled trials with long-term follow-up visits are necessary. In light of high satisfaction and low complication rates, the FCI flap should be considered as an equal option for autologous breast reconstruction.
Conclusion
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The free FCI flap is a safe method for breast reconstruction with low rates of flap loss and complications. Fast postoperative mobilization along with good patient satisfaction can be achieved. The FCI flap should be considered as a worthy option for autologous breast reconstruction.
Conflict of interest
None.
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Funding
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The authors have no conflict of interest to declare.
References
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4. Windhofer C, Papp C, Staudach A, Michlits W. Local fasciocutaneous infragluteal (FCI) flap for vulvar and vaginal reconstruction: a new technique in cancer surgery. Int J Gynecol Cancer 2012: 22: 132-8. 5. Scheufler O, Farhadi J, Kovach SJ, et al. Anatomical basis and clinical application of the infragluteal perforator flap. Plast Reconstr Surg 2006: 118: 1389-400. 6. Scheufler O, Farhadi J, Pierer G, Levin LS, Erdmann D. [The infragluteal perforator flap]. Handchir Mikrochir Plast Chir 2006: 38: 390-7. 7. Windhofer C, Brenner E, Moriggl B, Papp C. Relationship between the descending branch of the inferior gluteal artery and the posterior femoral cutaneous nerve applicable to flap surgery. Surg Radiol Anat 2002: 24: 253-7. 8. Hartrampf CR, Scheflan M, Black PW. Breast reconstruction with a transverse abdominal island flap. Plast Reconstr Surg 1982: 69: 216-25. 9. Allen RJ, Treece P. Deep inferior epigastric perforator flap for breast reconstruction. Ann Plast Surg 1994: 32: 32-8. 10. Papp C, Wechselberger G, Schoeller T. Autologous breast reconstruction after breast-conserving cancer surgery. Plast Reconstr Surg 1998: 102: 1932-6; discussion 37-8. 11. Papp C, Windhofer C, Michlits W. Autologous breast augmentation with the deepithelialized fasciocutaneous infragluteal free flap: a 10-year experience. Ann Plast Surg 2011: 66: 587-92. 12. Hamdi M, Greuse M, De Mey A, Webster MH. A prospective quantitative comparison of breast sensation after superior and inferior pedicle mammaplasty. Br J Plast Surg 2001: 54: 39-42. 13. Schlenz I, Rigel S, Schemper M, Kuzbari R. Alteration of nipple and areola sensitivity by reduction mammaplasty: a prospective comparison of five techniques. Plast Reconstr Surg 2005: 115: 743-51; discussion 52-4. 14. Moscona RA, Holander L, Or D, Fodor L. Patient satisfaction and aesthetic results after pedicled transverse rectus abdominis muscle flap for breast reconstruction. Ann Surg Oncol 2006: 13: 1739-46. 15. Bodian CA, Freedman G, Hossain S, Eisenkraft JB, Beilin Y. The visual analog scale for pain: clinical significance in postoperative patients. Anesthesiology 2001: 95: 1356-61. 16. Baryza MJ, Baryza GA. The Vancouver Scar Scale: an administration tool and its interrater reliability. J Burn Care Rehabil 1995: 16: 535-8. 17. Aird LN, Bristol SG, Phang PT, Raval MJ, Brown CJ. Randomized double-blind trial comparing the cosmetic outcome of cutting diathermy versus scalpel for skin incisions. Br J Surg 2015: 102: 489-94. 18. Braam KI, Kooijmans EC, van Dulmen-den Broeder E, et al. No efficacy for silicone gel sheeting in prevention of abnormal scar formation in children with cancer: a randomized controlled trial. Plast Reconstr Surg 2015: 135: 1086-94. 19. Sood R, Roggy DE, Zieger MJ, et al. A comparative study of spray keratinocytes and autologous meshed split-thickness skin graft in the treatment of acute burn injuries. Wounds 2015: 27: 31-40. 20. Weinstein S. Fifty years of somatosensory research: from the Semmes-Weinstein monofilaments to the Weinstein Enhanced Sensory Test. J Hand Ther 1993: 6: 1122; discussion 50. 21. Januszyk M, Gurtner GC. Statistics in medicine. Plast Reconstr Surg 2011: 127: 437-44. 22. Wang XL, Liu LB, Song FM, Wang QY. Meta-analysis of the safety and factors contributing to complications of MS-TRAM, DIEP, and SIEA flaps for breast reconstruction. Aesthetic Plast Surg 2014: 38: 681-91.
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23. Lu SM, Nelson JA, Fischer JP, et al. The impact of complications on function, health, and satisfaction following abdominally based autologous breast reconstruction: a prospective evaluation. J Plast Reconstr Aesthet Surg 2014: 67: 682-92. 24. Truong PT, Lee JC, Soer B, Gaul CA, Olivotto IA. Reliability and validity testing of the Patient and Observer Scar Assessment Scale in evaluating linear scars after breast cancer surgery. Plast Reconstr Surg 2007: 119: 487-94. 25. Truong PT, Abnousi F, Yong CM, et al. Standardized assessment of breast cancer surgical scars integrating the Vancouver Scar Scale, Short-Form McGill Pain Questionnaire, and patients' perspectives. Plast Reconstr Surg 2005: 116: 1291-9. 26. Ludolph I, Horch RE, Harlander M, et al. Is there a Rationale for Autologous Breast Reconstruction in Older Patients? A Retrospective Single Center Analysis of Quality of life, Complications and Comorbidities after DIEP or ms-TRAM Flap Using the BREAST-Q. Breast J 2015: 21: 588-95. 27. Donabedian A. Evaluating the quality of medical care. Milbank Mem Fund Q 1966: 44: Suppl:166-206. 28. Bar-Meir ED, Yueh JH, Hess PE, et al. Postoperative Pain Management in DIEP Flap Breast Reconstruction: Identification of Patients With Poor Pain Control. Eplasty 2010: 10. 29. Weichman KE, Hamill JB, Kim HM, et al. Understanding the recovery phase of breast reconstructions: Patient-reported outcomes correlated to the type and timing of reconstruction. J Plast Reconstr Aesthet Surg 2015: 68: 1370-8. 30. Fansa H, Schirmer S, Warnecke IC, Cervelli A, Frerichs O. The transverse myocutaneous gracilis muscle flap: a fast and reliable method for breast reconstruction. Plast Reconstr Surg 2008: 122: 1326-33. 31. Craggs B, Vanmierlo B, Zeltzer A, et al. Donor-site morbidity following harvest of the transverse myocutaneous gracilis flap for breast reconstruction. Plast Reconstr Surg 2014: 134: 682e-91e. 32. Deutinger M, Kuzbari R, Paternostro-Sluga T, et al. Donor-site morbidity of the gracilis flap. Plast Reconstr Surg 1995: 95: 1240-4. 33. Pulzl P, Schoeller T, Kleewein K, Wechselberger G. Donor-site morbidity of the transverse musculocutaneous gracilis flap in autologous breast reconstruction: shortterm and long-term results. Plast Reconstr Surg 2011: 128: 233e-42e. 34. Wechselberger G, Schoeller T. The transverse myocutaneous gracilis free flap: a valuable tissue source in autologous breast reconstruction. Plast Reconstr Surg 2004: 114: 69-73. 35. Fujino T, Harasina T, Aoyagi F. Reconstruction for aplasia of the breast and pectoral region by microvascular transfer of a free flap from the buttock. Plast Reconstr Surg 1975: 56: 178-81. 36. Allen RJ, Levine JL, Granzow JW. The in-the-crease inferior gluteal artery perforator flap for breast reconstruction. Plast Reconstr Surg 2006: 118: 333-9. 37. Levine JL, Miller Q, Vasile J, et al. Simultaneous bilateral breast reconstruction with in-the-crease inferior gluteal artery perforator flaps. Ann Plast Surg 2009: 63: 249-54. 38. Spiegel AJ, Menn ZK, Eldor L, Kaufman Y, Dellon AL. Breast Reinnervation: DIEP Neurotization Using the Third Anterior Intercostal Nerve. Plast Reconstr Surg Glob Open 2013: 1: e72. 39. Blondeel PN, Demuynck M, Mete D, et al. Sensory nerve repair in perforator flaps for autologous breast reconstruction: sensational or senseless? Br J Plast Surg 1999: 52: 37-44.
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ACCEPTED MANUSCRIPT 40. Sinis N, Lamia A, Gudrun H, Schoeller T, Werdin F. Sensory reinnervation of free flaps in reconstruction of the breast and the upper and lower extremities. Neural Regen Res 2012: 7: 2279-85. 41. Parrett BM, Caterson SA, Tobias AM, Lee BT. The rib-sparing technique for internal mammary vessel exposure in microsurgical breast reconstruction. Ann Plast Surg 2008: 60: 241-3. 42. Yap LH, Whiten SC, Forster A, Stevenson HJ. Sensory recovery in the sensate free transverse rectus abdominis myocutaneous flap. Plast Reconstr Surg 2005: 115: 1280-8. 43. Clough KB, O'Donoghue JM, Fitoussi AD, Vlastos G, Falcou MC. Prospective evaluation of late cosmetic results following breast reconstruction: II. Tram flap reconstruction. Plast Reconstr Surg 2001: 107: 1710-6.
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ACCEPTED MANUSCRIPT Figure 1: Anatomy of FCI Flap
Figure 2: surgical markings FCI Flap
Figure 3: Postoperative complications during in-patient time •
wound healing disorder, WHD
Figure 4: Visual Analog Scale for postoperative pain rating
Figure 5a: Vancouver Scar Scale reconstructed breast
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Figure 5b: Vancouver Scar Scale donor site
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Figure 6a, b: 44 years old patient, three months after fci flap for breast reconstruction on the right side, classified as Vancouver Scar Scale Score 2 (separate upload).
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Figure 7 a, b: donor site six weeks postoperatively, classified as Vancouver Scar Scale Score 4 (separate upload)
ACCEPTED MANUSCRIPT Table 1: Investigated parameters of satisfaction survey Type of variable
Change in sexual intercourse
I (low) to 5 (high) Yes/ no Yes/ no
Categorical, dichotomous Categorical, dichotomous Numerical Numerical Numerical
Yes/ no Yes/ no I (non) to 5 (normal) I (non) to 5 (normal) I (very) to 5 (not at all)
Numerical Numerical Numerical Numerical Numerical
I (no) to 5 (yes) I (low) to 5 (high) I (low) to 5 (high) I (low) to 5 (high) I (low) to 5 (high)
Numerical Numerical
Numerical
Change in woman’s attitude to spouse
Numerical
Numerical
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Sexual relationship with spouse
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Numerical Categorical, dichotomous Categorical, dichotomous
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General satisfaction Satisfaction with outcome Would you repeat the procedure Recommend to a friend Specific aspects of satisfaction and surgical outcome Everyday difficulty Difficulty in strenuous exercise Touch sensation breast Touch sensation infragluteal Disturbance from infragluteal scar Aesthetic aspects Symmetry of breasts Satisfaction with breast scars Satisfaction with appearance in clothes Satisfaction with nude appearance Aesthetic satisfaction Effect of procedure on relationship with spouse Satisfaction of spouse with procedure Change in attraction of spouse
Range
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Variable
I (no) to 5 (yes) I (worse), 2 (no change), 3 (better) I (worse), 2 (no change), 3 (better) I (worse), 2 (no change), 3 (better) I (worse), 2 (no change), 3 (better)
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Range 1 (low) to 5 (high) Yes/ no Yes/ no
4.0 Yes 88.9%; No 11.1% Yes 85.2%; No 14.8%
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Satisfaction with outcome Would you repeat the procedure Recommend to a friend
Median
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Range 1 (no) to 5 (Yes) 1 (low) to 5 (high) 1 (low) to 5 (high) 1 (low) to 5 (high) 1 (low) to 5 (high)
4.0 4.0 5.0 4.0 4.0
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Symmetry of breasts Satisfaction with breast scars Satisfaction with clothed appearance Satisfaction with nude appearance Aesthetic satisfaction
Median
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Range
Satisfaction of spouse with procedure Change in attraction of spouse Change in sexual intercourse Change in woman`s attitude to spouse
I (no) to 5 (Yes) I (worse), 2 (no change), 3 (better) I (worse), 2 (no change), 3 (better) I (worse), 2 (no change), 3 (better) I (worse), 2 (no change), 3 (better)
4.0 2.0 2.0 2.0 2.0
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Sexual relationship with spouse
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2
cardiovascular
2
revisions of anastomosis
3
seroma infragluteal
6
WHD* breast
6
haematoma breast
6
WHD* infragluteal
17 20 40 60 80 Number of patients (n=108)
100
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neuropathy infragluteal
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average 4.2± 2.5
20
17 15
15
13 11
10
10 6 5
4
3
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Number of patients (n=108)
30
3
1
0 1
2
3
4 5 6 Visual Analog Scale
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Figure 2: Visual Analog Scale for postoperative pain rating
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9
10
0 0 0 0 0 0 0 0 0 0
0 = normal skin 14 = worst scar quality
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14 13 12 11 10 9 8 7 6 5 4 3 2 1 0
22
16 1 5
10 15 Number of patients (n=47)
20
25
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Vancouver Scar Scale
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3
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Vancouver Scar Scale (VSS)
Figure 3a: Vancouver Scar Scale reconstructed breast
25 17
2
0
0
5
10 15 Number of patients (n=47)
Figure 3b: Vancouver Scar Scale donor site
20
25
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