Breast Reconstruction Flashcards

Question

What is the source and course of the DIEA and its perforators

Answer 1

Source: External Iliac artery Size: 2.5mm diamter, 5cm length Course * deep to rectus, enters at lateral mid 1/3 of muscle * enters muscle at arcuate line, approx 4cm above public tubercle * two rows of perforators * medial row - within 1cm of linea alba * lateral row - withni 2cm of linea semilunaris

Answer 2

Innervation: segmental innervation from T8-T12 intercostals, course lateral to medial between internal oblique and trasnversus abdominis Mixed nerves enter laterally - sensory nerves run with perforators - motor nerves run over the DIEA

Answer 3

Abdominal wall composed of EO, IO, tranversus abdominus and rectus abdominis Anterior rectus sheath above arcuate is composed of * EO, IO -\> posterior sheath is composed of IO and TA aponeurosis Anterior rectus sheath below arcute line is composed of * EO, IO, transversus abdominus - \> so the posterior sheath is ONLY composed of transversalis fascia - no aponeurosis Origin of Rectus abdominis - superior crest and pubic symphysis Insertion - costal cartilage 5,6,7

Answer 4

* Type 1 - single intramuscular vessel from DIEA to SEA * Type 2 -(majority 60%) DIEA branches into medial and lateral rows and the arcuate line and communicate with SEA * Type 3 - (minotrty 30%) DIEA branches into 3 at the arcuate line

Answer 5

Superior epigastric artery BUT - dominant abdominal vascular supply is DIEA - so para and infraumbilicl perforators supply abdominal skin via choke vessels in retrograde flow to SEA - axial perforators supply lateral extnsion of TRAM across the midline - so can raise nearly whoke TRAM on one pedicle

Answer 6

HARTRAMF - described for pedicled TRAM Zone 1 - ipsilat to pedicle, periumbilical * Zone 2 - contralat to pedicle, periumbilical* * Zone 3 - Ipsilat to pedicle, lateral flap portion* Zone 4 - contralat to pedicle, lateral flap portion NINKOVIC - described for free TRAM Zone 1 - ipsilat to pedicle, periumbilical * Zone 2 - Ipsilat to pedicle, lateral flap portion* * Zone 3 - contralat to pedicle, periumbilical* Zone 4 - contralat to pedicle, lateral flap portion

Answer 7

Hartrampf dimensions on average Vertical width: 13cm (will be equal to base of breast to be created Width - from ASIS to ASIS, approx 36cm On a pedicled TRAM, can harvest zone 1, all or some of zone 3 (contralat periumbilicail) and some of zone 2 (ipsilat, lateral zone)

Answer 8

ADVANTAGES - Simultaneous abdominoplasty - acceptable donor scar - shorter OR, LOS - versatile, natural, permanent DISADVANTAGES - donor site morbidity (hernia/bulge) - long recovery/RTW

Answer 9

* habitus * refusal for alloplastic materials * unable to tolerate long OR

Answer 10

EARLY **Recipient Site** * Partial flap loss, Total flap loss * Mastectomy flap necrosis * hematoma, seroma **Donor Site** * necrosis of abdominal flap * umbilical necrosis **Medical/systemic** - DVT/PE, renal injury LATE **Recipient Site** * Fat necrosis **Donor Site** * Abdominal weakness, bulge, hernia * Ubilical malposition * Mesh infection/extrusion * contour irregularities * abdominal dysesthesia

Answer 11

* reconstruction requiring more volums than provided by a single pedicled TRAM * midline vertical lower abdoinal scar

Answer 12

Advantages * more volume and skin for recosntruction of breast * improved blood supply in those at risk of poor perfusion (hartrampf zone 2 is contralat periumbilical) Disadvantages * abdominal weakening, increase risk hernia/bulge * difficulty shaping breast * difficulty closing abdominal wall defect

Answer 13

* Supercharging : additional microvascular anastomosis between DIEA/V and TD A/V to provide a second source of arterial perfusion and venous drainage * Turbocharging: transmidline retrograde microvascular loop of DIEA/V to provide increased arterial inflow to zone 4 and venous outflow * Vascular delay procedure: ligate SIEA/SIEV bilaterally 2-3weeks prior to flap elevation - increases arterial pressure, decrease venous congestion and fat necrossis * Indicated if large volume TRAM in high risk patient unsafe to undergo DIEP

Answer 14

LANDMARKS - Inguinal crease, ASIS, umbilicus MARKINGS - ASIS to ASIS with superior line above umbilicus and inferior line in suprapubic crease. Test laxity for closure - design flap ipsilat for 90' rotation, measure base width and height, include zone 1, some of zone 2 and some of zone 3 STEPS OF OPERATION 1- Recreation of defect - excise Mx scar, create pocket, tunnel, score superior edge of mastectomy flap to allow for expansion and create dart in skin at anterior axillary line 2- Elevation of flap to pedicle * superior incision, raise to subcostal amrgin, create tunnel * umbilical separation * inferior incision, raise lateral to medial ipsilat side - stop once reached rectus muscle * on contralat side, raise lat to medial until reached linea alba and leave 1cm cuff on ipsi side for closure with mesh 3- Pedicle dissection * incise fascia ontop of muscle and just lateral to perforators to minimze amount of fascia removed * from medial to lateral, raise muscle off fascia and identify pedicle. * careful at inscriptions (perforators may be present) @ xphoid, @ umb and midway between * pedicle location midpoint between ASIS and pubic symphysis along lateral margin of muscle 4- Inset of flap * turn 90degrees * inset IMF and medially first 5- Donor site closure * Abdo wall repair with prolene mesh both external and internal oblique layers * closure of scarpas fascia and umbo inset

Answer 15

MN5 dominant - Td - length8-10cm, 2.5mm diameter Segmental - Intercostal perforators Thoracic T6-12 and lumbar

Answer 16

Origin: thoracolumbar fascia, iliac creast, T6-T12 spinous processes Insertion: bicipital groove of humerus Innervation: thoracodorsal nerve (posterior cord) Function: Internal rotation, adduction

Answer 17

Indications - Hx of Rtx - no abdominal tissue for reconstruction - salavge procedure for imminent exposure of implant - poland syndrome Adv - reliable - short recovery, LOS - restore anterior axillary line Disadv - difficult positioning for bilateral recon - minimal tissue bulk - generally combine dwith alloplastic material - shoulder weakness, scapula winging - seroma, thoracolumbar hernia

Answer 18

FC flap based on superior epigastric artery and subcostal arteries - boundaries: midline (medial), midaxillary line (lateral), midway b/w xiphoid and umbo (inferior, xiphoid (superior) - elevate lateral to medial, suprafascial to linea semilunaris

Answer 19

Can be raised as a Muscle sparing flap ## Footnote MS 0 - no muscle spared MS 1 - lateral band of muscle spared MS 2 - lateral and medial band of muscle spared MS 3 - preservation of entire muscle (perforator flap)

Answer 20

INDICATION * divide SEA * abdominal scar precluding pedicled tram * ratio of donor site to breast volume is low CONTRAINDICATION * abdominal scar/surgery precluding use of DIEA (paramedian scar, inguinal hernia repair * abdominoplasty * lack of donor tissue * medically unfit

Answer 21

AdV * more robust blood supply, reduced fat necrosi * less muscle harvest, reduced morbidity * no subcut tunnel DisAdv * long OR, rehab, RTW * systemic risks VTE * flap loss

Answer 22

Total flap loss - highest SIEA, rest equal Partial flap loss and fat necrosis - pedicled tram \>\>\>free tram/diep Abdominal hernia/bulge pedicled tram 15%\> free tram/diep 10% SIEA 0%

Answer 23

MN1 - deep circumflex iliac artery with small cuff of EO, IO, transversus

Answer 24

1. Superior gluteal myocutaneous flap (SGM) 2. Inferior gluteal myocutaneous flap (IGM) 3. Superior gluteal artery perforator (SGAP) 4. Inferior gluteal artery perforator (IGAP)

Answer 25

Origin: gluteal line ilium, aponeurosis erector spinae, Sacrotuberous ligament, sacrum/coccyx Insertion: iliotibial tract, gluteal tuberosity of femur Function - extend and rotate externally Innervation superior clunial n L1-3 medial clunial nerve S1-3 posterior femonal n Vascular supply MN3 - 2 dominant - terminal branches of internal iliac - superior and inferior gluteal arteries, exit above and below piriformis from the greater scaitic foramen - inferior is dominant to supplying gluteus maximus

Answer 26

LANDAMRKS * PSIS to greater trochanter line - at junction of upper 1/3 and lower 2/3 is pedicle location ellipse oritented oblique, width 13cm ELEVATION * start at superior incision and find lateral border of . maximus. * dissect b/w maximus and medius and identify pedicle 5cm from scarum, between piriformis and medius * divdie deep br of SGA and raise only superior 1/3 of muscle

Answer 27

Indication - too thin for abdominal flap - preference of pt surgeon Adv - well hidden scar, buttock lift - always available, good shape Disadv - short pedicle - intra-op position difficult for 2nd team - hip extension weakness

Answer 28

LANDMARK * flap central axis is perpendicular to gluteal crease and * 1/2 way b/w PSIS and ischial tubersotiy is pedicle exit from pelvis * flap designed between trochanter and ishium vertically along post thigh ELEVATION * elevate inferior to superior, through fascia lata and disinsert muscle below GT * watch for scaitic nerve, post femoral n Disadvantgae - as above for SGM and post cut nerve sacrificed

Answer 29

MN1 - based on TFL, ascending branch of lateral circumflex femoral artery LANDMARKS - 10cm below ASIS, pedicle enters deep surface of TFL

Answer 30

MN2 - medial circumflex femoral artery, superficial femoral br LANDMARK * adductor longus tendon. Gracilis is posterior and medial * pedicle runs posterior to adductor longus Innervation obturator nerve

Answer 31

2x fat necrosis 2x flap loss and thrombosis 1-2x abdominal bulge

Answer 32

INDICATION * \<70% of tram tissue required CONTRAINDICATION * intraop unable to identify suitable perforator Adv - no muscle harvest, shorter recovery Diadv - tehcnically difficult

Answer 33

SIEA - superficial inferior epigastric artery flap Superficial system present in 70%, suitable in 30% SIEA arises from SCIA or CFA LANDMARK * ASIS, inguinal ligament, pubis * pedicle arises deep to scarpas, 1-3cm below inguinal ligament and travels superior lateral, crossing inguinal lig at midpoint b/w ASIS and pubis PEDICLE 4-6cm

Answer 34

if \<50% abdomen required, SIEA 50% required DIEP \>70% required TRAM

Answer 35

LANDMARKS * draw line b/w PSIS and cocyx; at midpoint of line, (P) connect to greater trochanter = marks upper edge of piriformis * line from PSIS to GT outlines maximus muslce axis and at jx of upper 1/3 and lower 2/3rd is the pedicle * Pedicle exits 6cm inferior to PSIS and 5cm lateral to midline * Pedicle: superior gluteal artery exits from greater scaitic foramen, superior to piriformis, inferior to gluteus medius * perforators are found superior to piriformis and lateral to pedicle exit Flap design - ellipse 45' slant with apex ELEVATION - lateral superior, deep to fascia - identify perforator and trace down through muscle

Answer 36

LANDMARKS * PSIS to coccyx line, midpoint of line (P) to GT = upper edge of piriform muscle * PSIS to ischium - alongt his line, at inferior edge of piriformis muscle, pedicle exits * Flap designed 4cm above gluteal crease, width 10cm lateral to ischium ELEVATION * infero

Answer 37

* igap longer pedicle * donor site hidden in crease * potential for neurosensory flap

Answer 38

* IGA/V * sciatic n * intenal pudendal art * PCFN

Answer 39

* Oncologic * Expectations/desires * Aesthtic

Answer 40

* reduction * augmentation * mastpexy * augentation mastopexy * PM * no alteration note - only have one chance to recon oppost ebreast w abdo flap

Answer 41

* liposuction * lipofill * direct excision * IMF repositioning * scar revision

Answer 42

- superior aesthetic result - long lasting acceptable result

Answer 43

* Define PROBLEM * A/V thrombosis - take down, revemo clot, trim, redo, use anticoag/thrombolytic (IV heparin, IV tpa) If unsalvegable recipient, move to different site * if unsalveagable, TE insertion

Answer 44

NOn-surgical * tattoo * prosthesis Surgical * composite graft (contralat nipple, ear, toe pulp, labia majora * local flap- skate, cv flap Areaola rcon w STSG abdo groin