The angiosomes of the body and their supply to perforator flaps

L’utilisation des lambeaux dorsaux pédiculé épargnant le muscle grand dorsal (TDAP et MSLD flap) est une méthode de reconstruction bien décrite en reconstruction mammaire après cancer du sein. Néanmoins, peu de données existent concernant la satisfaction des patientes après cette chirurgie. L’objectif principal de cette étude a été d’évaluer la satisfaction des patientes après reconstruction mammaire secondaire totale unilatérale par lambeau TDAP ou MSLD. Les objectifs secondaires correspondaient à l’évaluation des complications postopératoires suite à cette chirurgie, l’évaluation de la durée de la reconstruction et de la nature des interventions complémentaires, l’évaluation des séquelles fonctionnelles, et l’évaluation de la taille de bonnet obtenue une fois la reconstruction terminée.

Il s’agit d’une étude de cohorte monocentrique et rétrospective, incluant 22 patientes opérées d’une reconstruction mammaire secondaire totale unilatérale par lambeau TDAP ou MSLD entre le 1^er janvier 2018 et le 31 décembre 2022. La satisfaction des patientes a été évaluée à l’aide de trois questionnaires validés en reconstruction mammaire : le module Reconstruction du BREAST-Q, le MBROS-S et le MBROS-BI.

Le score de satisfaction du MBROS-S est de 71,4 %. Le score d’image corporelle du MBROS-BI est de 62 %. Grâce au BREAST-Q, le score de satisfaction vis-à-vis de la poitrine est évalué à 53,1 ; le score de satisfaction concernant le dos est évalué à 75,5 ; le score de bien-être physique concernant la poitrine est évalué à 71,7 ; le score de bien-être physique concernant l’épaule et le dos est évalué à 67,4 ; le score de bien-être psychosocial est évalué à 67,4 ; le score de bien-être sexuel est estimé à 48,7 ; et pour les femmes ayant bénéficié d’une reconstruction associée à une prothèse, le score de satisfaction concernant l’implant est de 71,6.

La reconstruction mammaire secondaire totale unilatérale par lambeau pédiculé dorsal épargnant le muscle grand dorsal est une manière élégante, fiable et respectueuse de reconstruire un sein, et semble donner des niveaux de satisfaction élevés aux patientes qui en bénéficient.

The use of pedicled dorsal flaps sparing the latissimus dorsi muscle (TDAP and MSLD flap) is a well-described reconstruction method in breast reconstruction after breast cancer. However, little data exists regarding patient satisfaction after this surgery. The main objective of this study was to evaluate patient satisfaction after unilateral total secondary breast reconstruction using a TDAP or MSLD flap. The secondary objectives corresponded to the evaluation of postoperative complications following this surgery, the evaluation of the duration of the reconstruction and the nature of additional interventions, the evaluation of the functional after-effects, and the evaluation of the chest size when the reconstruction is completed.

This is a monocentric, retrospective cohort study, including 22 patients who underwent unilateral secondary total breast reconstruction using a TDAP or MSLD flap between January 1, 2018 and December 31, 2022. Patient satisfaction was assessed using three questionnaires validated in breast reconstruction: the Reconstruction module of the BREAST-Q, the MBROS-S and the MBROS-BI.

The MBROS-S satisfaction score is 71.4%. The MBROS-BI body image score is 62%. With the BREAST-Q, the Satisfaction with Breast score is estimated at 53.1; the Satisfaction with Back score is estimated at 75.5; the physical well-being score regarding the chest is evaluated at 71.7; the physical well-being score concerning the shoulder and back is evaluated at 67.4; the psychosocial well-being score is assessed at 67.4; the sexual well-being score is estimated at 48.7; and for women who have benefited from reconstruction associated with a prosthesis, the satisfaction score regarding the implant is 71.6.

Unilateral total secondary breast reconstruction with a dorsal pedicled flap sparing the latissimus dorsi muscle is an elegant, reliable, and respectful way to reconstruct a breast, and appears to give high levels of satisfaction.

The use of perforator mapping has become routine for many microsurgeons in the planning and performing of free flaps in breast reconstructions. Within this field, the number of available technologies and their quality has rapidly evolved over time. This study presents an up-to-date review on the spectrum of alternative perforator mapping modalities and the efficiency and utilization in the practice of free flap breast reconstructive surgery.

Extensive searches of the PubMed and Embase databases were performed. Articles containing free flap tissue transfer in breast reconstruction and a perforator imaging modality were included. Qualitative and descriptive analyses of the outcomes were performed, and the quality of the evidence was appraised.

One hundred and sixty-eight articles were included. Besides the routinely used handheld Doppler, CT angiography, and MR angiography, seven alternative technologies (38 studies) have been found; color Doppler fluorescent angiography, dynamic infrared thermography, image-guided stereotaxy, template, 3D printed model, and augmented reality. The modalities were classified based on their concept of imaging as volumetric perforator imaging, real-time perforator imaging, and complementary techniques. A poor level of evidence for each alternative modality was found.

An overview of alternative imaging techniques available to pre- and intraoperatively map perforator locations have been given. Several novel promising techniques have been identified, all to be used in conjunction with volumetric imaging. This overview provides a perspective on the future field of imaging in reconstructive surgery.

Reconstruction of soft tissue defects in lower limb fractures requiring internal fixation remains a challenging scenario with the optimal surgical treatment still debated. This study aims to recommend, and eventually redefine, surgical indications for propeller flaps reconstruction in the distal lower limb, with a particular focus on the presence or not of metalwork.

A retrospective study of lower limb soft tissue reconstructions performed between January 2015 and July 2018 was carried out including all patients treated with a propeller perforator flap (PPF) with at least 6-month follow-up. Patients were further divided in 2 groups depending on the presence of metalwork fixation beneath the flap (F group, propeller on Framework; NF group, propeller with No-Framework).

21 patients were retained (F group, 11 patients; NF group, 10 patients). There were no significant differences between the two groups in age, BMI, ASA scores, comorbidities or defect size. There was a statistically significant difference between the groups (p<0.05) in the cumulative hospital stay with a mean cumulative hospital stay of 22 ± 9 days in the F group and 12 ± 8 days in NF group. Failures were higher where PPF were used to cover hardware material, with 3 patients requiring a major secondary procedure in F group versus 1 patient in NF group.

The presence of underlying metalwork significantly reduced the margin for small, day-case revision procedures such as flap readvancement or STSG. This study emphasizes clinical intuition that whilst PPF are a useful and elegant tool in lower limb reconstruction, their use should be limited when underlying metalwork is present.

Resorting to perforators as recipient vessels is a valid alternative that might offer a series of advantages in many situations. They allow the use of a shorter pedicle, reduce the time of dissection, and are a good solution when deep vessels are difficult to reach. The aim of this study is to investigate the efficacy of P-to-P tissue transfer for reconstructing defects in different areas of the body.

Between April 2018 and February 2020, 40 patients presenting soft tissue defects were reconstructed by using P-to-P-anastomosed free flap transfer. The cause of the defect was trauma in 16 cases and surgically excised tumor in 24. Five defects were located in the upper extremities, 1 in the neck, 1 in the thorax, and 21 in the lower limb, and 13 cases were breast reconstructions, 2 of which bilateral (43 total flaps).

Of all 43 flaps, 22 were abdominal flaps, 17 flaps were harvested from the upper thigh, and 4 were harvested from the lower leg. At the 9 month follow-up, 42 flaps were successfully healed, 36 without complications, 3 after wound dehiscence, and 3 after wound infection, and only 1 flap was lost requiring further surgery. Flap failure rate was 2.3%.

Free flaps anastomosed in perforator-to-perforator fashion can be safely used in different settings throughout the body. Even if they are technically more demanding, they may allow a quicker operation time and lower morbidity. With the developments in microsurgical instruments, we believe that this technique may become the gold standard for tissue-defect reconstruction.