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The In-the-Crease Inferior Gluteal Artery Perforator Flap for Breast Reconstruction
Even with the use of AlloDerm, I was somewhat disappointed by the results reported by the authors. The first 18 patients had a seroma rate of over 44% and a bulge rate of over 33%. Even after the authors revised their technique, the seroma rate was 16.7% and the bulge rate was 16.7%, which are both high, in my opinion. I believe that the best way to avoid donor site morbidity is to harvest the fascia using the fascia-sparing technique and to close the fascia defect primarily without using any fascial substitutes such as mesh or AlloDerm. If a fascial substitute is required to close the fascia, in a clean and uncompromised setting, the type of substitute used probably makes little difference. The best substitute is the one that is readily available, easy to work with, and relatively inexpensive. D. W. Chang, MD
The In-the-Crease Inferior Gluteal Artery Perforator Flap for Breast Reconstruction
reducing capsular contracture compared with smooth-surface implants in patients undergoing breast augmentation. The study concluded that textured-surface implants do have a significantly lower rate of capsular contracture in this patient group, except when the implants are placed submuscularly. This finding confirms what we already know; currently, most surgeons do place implants submuscularly for augmentation or reconstruction because of their lower capsular contracture rate regardless of whether textured or smooth implants are used. One thing that this study did not look at is whether the implant type— saline or silicone gel—had any effect on the rate of capsular contracture. A similar study looking at the capsular contracture rate in patients undergoing breast reconstruction with implants would also be useful. D. W. Chang, MD
Breast Reconstruction With Gluteal Artery Perforator Flaps
Allen RJ, Levine JL, Granzow JW
Granzow JW, Levine JL, Chiu ES, et al
Plast Reconstr Surg 188:333-339, 2006
J Plast Reconstr Aesthet Surg 59:614-621, 2006
In this article from the Louisiana State University Health Sciences Center, the authors presented a series of 31 patients who underwent breast reconstruction with the in-the-crease inferior gluteal artery perforator flap. They reported improved donor-site appearance and patient satisfaction with this technique in which the scar is placed in the inferior buttock crease. In their opinion and on the basis of their experience with 279 gluteal flaps (220 superior, 59 inferior) since 1993, the in-thecrease inferior gluteal artery flap in the appropriately selected patient provides adequate tissue for breast reconstruction with minimal donorsite morbidity and improved pedicle length, which provides better insetting and orientation of the flap compared with the superior gluteal artery perforator flap. The flap loss and complication rates reported in this series are similar to those found with other perforator flaps. The indications for the use of gluteal perforator flaps as outlined by the authors are inadequate abdominal tissue, patient choice, prior deep inferior epigastric perforator (DIEP) flap, prior failed transverse rectus abdominis myocutaneous (TRAM) flap, and prior abdominal liposuction. The factors limiting the use of these flaps are well known and include the technical expertise needed to perform the dissection, the amount of tissue transfer and the quality of the tissue, patient positioning, and vulnerability of the sciatic nerve. Despite the surgeon’s ability to hide the scar in the gluteal crease, there still exists a lateral extension of the scar and the chance of a contour deformity as compared with the contralateral side, which may require revision. In our experience, patients with smaller, non-ptotic breasts who are undergoing immediate unilateral reconstruction and who have a fat distribution in the buttock region conducive to flap transfer are the preferred candidates for gluteal flaps. With appropriate patient selection and surgical experience, the use of the in-the-crease inferior gluteal artery perforator flap, as described by the authors, provides an aesthetically pleasing alternative for patients undergoing breast reconstruction who may not be appropriate candidates for traditional abdominal perforator flaps. M. A. Crosby, MD
This paper described the use of flaps based on either the superior or inferior gluteal blood vessels as a technique for autologous-tissue breast reconstruction after mastectomy. These flaps are harvested as perforator flaps, meaning that the surrounding muscle tissue is dissected away from the nutrient blood vessels, resulting in a flap that consists only of skin and subcutaneous fat. In theory, this approach reduces donor-site morbidity and preserves muscular function. The authors stated that the inferior gluteal artery perforator (IGAP) flap is preferred over the superior gluteal artery perforator (SGAP) flap, primarily because of the former’s longer vascular pedicle length and better donor-site appearance after surgery. Both the development of perforator flaps in place of myocutaneous flaps and the use of buttock tissue for breast reconstruction are important contributions to the field of reconstructive breast surgery. In our practice, SGAP and IGAP flaps are secondary choices for breast reconstruction because they are associated with an increased length of surgery, due primarily to position changes needed during surgery, and the technical challenges associated with short pedicle length and vessel diameter. The IGAP flap remains in the early stages of refinement but shows promise as an alternative to the transverse rectus abdominis myocutaneous flap when adequate abdominal tissue is not available. M. M. Hanasono, MD
Textured Surface Breast Implants in the Prevention of Capsular Contracture Among Breast Augmentation Patients: A Meta-Analysis of Randomized Controlled Trials Barnsley GP, Sigurdson LJ, Barnsley SE Plast Reconstr Surg 117:2182-2190, 2006 Capsular contracture can be a significant problem for patients undergoing breast augmentation or breast reconstruction with implants. This meta-analysis assessed the effect of textured-surface breast implants in
102 102
®
Breast Diseases: A Year Book Quarterly Vol 18 No 1 2007
Comparisons of Resource Costs and Success Rates Between Immediate and Delayed Breast Reconstruction Using DIEP or SIEA Flaps Under a Well-Controlled Clinical Trial Cheng MH, Lin JY, Ulusal BG, et al Plast Reconstr Surg 117:2139-2144, 2006 The data obtained in this well-designed controlled study apply unquestionably to the authors’ plastic surgical unit in Taiwan. However, I have reservations about whether the authors’ conclusions would apply to units in other countries. Two points are salient to me after reading the article. First, the authors did not take into account the cost of the mastectomy done as a separate procedure. Second, to this reviewer, there was a significantly higher number of complications with the superficial epigastric artery (SIEA) flap compared with the deep inferior epigastric perforator flap (DIEP). In most surgical units with which I am familiar, the mastectomy and immediate reconstruction are done at the same time by 2 separate teams, thus decreasing the total operating time and avoiding a second hospitalization. This translates into significant cost savings. Wellestablished teams of reconstructive surgeons also address symmetry of the contralateral breast at the same time, leaving only the nipple and areolar reconstruction and other refinements for a second operation,
The In-the-Crease Inferior Gluteal Artery Perforator Flap for Breast Reconstruction
reducing capsular contracture compared with smooth-surface implants in patients undergoing breast augmentation. The study concluded that textured-surface implants do have a significantly lower rate of capsular contracture in this patient group, except when the implants are placed submuscularly. This finding confirms what we already know; currently, most surgeons do place implants submuscularly for augmentation or reconstruction because of their lower capsular contracture rate regardless of whether textured or smooth implants are used. One thing that this study did not look at is whether the implant type— saline or silicone gel—had any effect on the rate of capsular contracture. A similar study looking at the capsular contracture rate in patients undergoing breast reconstruction with implants would also be useful. D. W. Chang, MD
Breast Reconstruction With Gluteal Artery Perforator Flaps
Allen RJ, Levine JL, Granzow JW
Granzow JW, Levine JL, Chiu ES, et al
Plast Reconstr Surg 188:333-339, 2006
J Plast Reconstr Aesthet Surg 59:614-621, 2006
In this article from the Louisiana State University Health Sciences Center, the authors presented a series of 31 patients who underwent breast reconstruction with the in-the-crease inferior gluteal artery perforator flap. They reported improved donor-site appearance and patient satisfaction with this technique in which the scar is placed in the inferior buttock crease. In their opinion and on the basis of their experience with 279 gluteal flaps (220 superior, 59 inferior) since 1993, the in-thecrease inferior gluteal artery flap in the appropriately selected patient provides adequate tissue for breast reconstruction with minimal donorsite morbidity and improved pedicle length, which provides better insetting and orientation of the flap compared with the superior gluteal artery perforator flap. The flap loss and complication rates reported in this series are similar to those found with other perforator flaps. The indications for the use of gluteal perforator flaps as outlined by the authors are inadequate abdominal tissue, patient choice, prior deep inferior epigastric perforator (DIEP) flap, prior failed transverse rectus abdominis myocutaneous (TRAM) flap, and prior abdominal liposuction. The factors limiting the use of these flaps are well known and include the technical expertise needed to perform the dissection, the amount of tissue transfer and the quality of the tissue, patient positioning, and vulnerability of the sciatic nerve. Despite the surgeon’s ability to hide the scar in the gluteal crease, there still exists a lateral extension of the scar and the chance of a contour deformity as compared with the contralateral side, which may require revision. In our experience, patients with smaller, non-ptotic breasts who are undergoing immediate unilateral reconstruction and who have a fat distribution in the buttock region conducive to flap transfer are the preferred candidates for gluteal flaps. With appropriate patient selection and surgical experience, the use of the in-the-crease inferior gluteal artery perforator flap, as described by the authors, provides an aesthetically pleasing alternative for patients undergoing breast reconstruction who may not be appropriate candidates for traditional abdominal perforator flaps. M. A. Crosby, MD
This paper described the use of flaps based on either the superior or inferior gluteal blood vessels as a technique for autologous-tissue breast reconstruction after mastectomy. These flaps are harvested as perforator flaps, meaning that the surrounding muscle tissue is dissected away from the nutrient blood vessels, resulting in a flap that consists only of skin and subcutaneous fat. In theory, this approach reduces donor-site morbidity and preserves muscular function. The authors stated that the inferior gluteal artery perforator (IGAP) flap is preferred over the superior gluteal artery perforator (SGAP) flap, primarily because of the former’s longer vascular pedicle length and better donor-site appearance after surgery. Both the development of perforator flaps in place of myocutaneous flaps and the use of buttock tissue for breast reconstruction are important contributions to the field of reconstructive breast surgery. In our practice, SGAP and IGAP flaps are secondary choices for breast reconstruction because they are associated with an increased length of surgery, due primarily to position changes needed during surgery, and the technical challenges associated with short pedicle length and vessel diameter. The IGAP flap remains in the early stages of refinement but shows promise as an alternative to the transverse rectus abdominis myocutaneous flap when adequate abdominal tissue is not available. M. M. Hanasono, MD
Textured Surface Breast Implants in the Prevention of Capsular Contracture Among Breast Augmentation Patients: A Meta-Analysis of Randomized Controlled Trials Barnsley GP, Sigurdson LJ, Barnsley SE Plast Reconstr Surg 117:2182-2190, 2006 Capsular contracture can be a significant problem for patients undergoing breast augmentation or breast reconstruction with implants. This meta-analysis assessed the effect of textured-surface breast implants in
102 102
®
Breast Diseases: A Year Book Quarterly Vol 18 No 1 2007
Comparisons of Resource Costs and Success Rates Between Immediate and Delayed Breast Reconstruction Using DIEP or SIEA Flaps Under a Well-Controlled Clinical Trial Cheng MH, Lin JY, Ulusal BG, et al Plast Reconstr Surg 117:2139-2144, 2006 The data obtained in this well-designed controlled study apply unquestionably to the authors’ plastic surgical unit in Taiwan. However, I have reservations about whether the authors’ conclusions would apply to units in other countries. Two points are salient to me after reading the article. First, the authors did not take into account the cost of the mastectomy done as a separate procedure. Second, to this reviewer, there was a significantly higher number of complications with the superficial epigastric artery (SIEA) flap compared with the deep inferior epigastric perforator flap (DIEP). In most surgical units with which I am familiar, the mastectomy and immediate reconstruction are done at the same time by 2 separate teams, thus decreasing the total operating time and avoiding a second hospitalization. This translates into significant cost savings. Wellestablished teams of reconstructive surgeons also address symmetry of the contralateral breast at the same time, leaving only the nipple and areolar reconstruction and other refinements for a second operation,