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PURPOSE: To evaluate the influence of minoxidil, a well known vasodilator, on ischemic flap necrosis prevention in rats. METHODS: Ventral cutaneous flaps, measuring 8x4cm, were designed in 20 Wistar rats based on the right cranial epigastric artery. In the experiment group, 50 mg/kg/day of minoxidil sulfate was administered by orogastric tube and the same amount of saline solution was administered to the control group. Such procedure was initiated 24h before surgery and kept once a day through the 7th postoperative day. Microcirculation was evaluated with laser fluxometry 24h before surgical procedure, at immediate postoperative and at the 7th postoperative day. Flap necrosis area was evaluated by 2 methods: planimetry and weight/paper ratio. RESULTS: A significant flow increase in distal and medial extremity at M1 (medial point 1) (p=0,0484) was observed in the experiment group. There was significant difference in flap necrosis prevention in the experiment group (p=0,0433), although after necrosis took place there was no significant difference in necrosis size. (p=0,1051 and p=0,2799). CONCLUSION: Minoxidil sulfate is effective in avoiding necrosis in ischemic flaps, but after necrosis is present there is no difference in survival area between experimental and control groups.

An insidious risk with the use of muscle perforator flaps is the possibility of venous outflow compromise. Congestion in deep inferior epigastric perforator (DIEP) flaps in particular is not infrequent. On an empiric basis, their salvage has been accomplished by augmenting venous drainage through alternative outflow tracts. The validity of this clinical maneuver can now best be tested in a rat DIEP flap model.The rat DIEP flap is a modification of the rat ventral abdomen flap. Flap perfusion can be based on a single rectus abdominis musculocutaneous perforator. No muscle is included with the flap. Three groups of five male Sprague-Dawley rats each were used. The conventional DIEP flap group had only a solitary perforator artery and venae comitantes and served as the control. The contralateral superficial inferior epigastric vein was included with the flap in the other two groups as a distinctly separate venous outflow tract. The latter two groups differed in that the perforator venae comitantes were either retained or deleted.Mean flap survival in the control DIEP flap group was 80.8 +/- 16.3 percent. Retention of the contralateral superficial inferior epigastric vein resulted in a statistically significant enhancement in flap viability (p0.027) whether the perforator venae comitantes were left intact (99.8 +/- 0.4 percent) or had been intentionally ablated (99.6 +/- 0.5 percent).Venous supercharging of the rat DIEP flap ensures greater flap survival. As a corollary, this supports the efficacy of prior anecdotal experiences in which an alternative venous outflow tract, preferably from the superficial system, had been used to overcome venous congestion. It is advisable for any muscle perforator flap to always try to retain a second outflow source to allow the potential for venous supercharging, if later indicated.

La reconstrucción mamaria postmastectomía puede suponer un importante consumo de recursos humanos y económicos para cualquier sistema sanitario. El propósito de este estudio es saber si el peso económico asignado por el Sistema Nacional de Salud Español según codificación mediante Grupos Relacionados con el Diagnóstico a los dos procedimientos principales de reconstrucción mamaria, se ajusta al gasto inferido según el consumo de recursos real de las pacientes. Realizamos un estudio retrospectivo de cohortes para evaluar el coste económico de 134 pacientes intervenidas de reconstrucción mamaria unilateral diferida mediante los procedimientos expansor-prótesis (E-P) y colgajo de perforantes de la arteria epigástrica inferior profunda (DIEP), durante el periodo comprendido entre 2005 y 2013. Los datos analizados e inferidos de las pacientes fueron los costes directos intrahospitalarios y extrahospitalarios tanto de la cirugía inicial de reconstrucción como de los procedimientos secundarios. Las pacientes reconstruidas con E-P precisaron un mayor número de cirugías para completar su reconstrucción, y presentaron mayor porcentaje de complicaciones relacionadas con la cirugía. El porcentaje de cirugías de retoque estético fue superior en la reconstrucción DIEP. No encontramos diferencias significativas en el coste total inferido de las pacientes entre ambas cohortes (18.857,77 € DIEP frente a 20.502,08 € E-P, p=0,89). El coste total de la reconstrucción mamaria según Grupos Relacionados con el Diagnóstico fue inferior al coste total inferido de las pacientes para ambas cohortes (11.596,43 € frente a 18.857,77 €, p

Previous studies showed that chlorogenic acid (CGA) accelerates wound healing via its antioxidant activity. We aimed to investigate the effect of CGA in an experimental epigastric abdominal skin flap model in nondiabetic and diabetic rats. Rats were firstly divided into 2 groups: nondiabetic and diabetic. Diabetes was induced by streptozotocin. Then, 4 subgroups were created for each group: vehicle as well as 0.2 mg/0.5 mL, 1 mg/0.5 mL, and 5 mg/0.5 mL CGA treatments. Right epigastric artery-based abdominal skin flaps were elevated and sutured back into their original position. Chlorogenic acid or vehicle was injected once into the femoral arteries by leaving the epigastric artery as the single artery feeding the flaps during the injection. On postoperative day 7, flap survivals were evaluated, and the rats were killed. Distal flap tissues were collected for histopathological and biochemical assays. Chlorogenic acid showed greater flap survival in both nondiabetic and diabetic rats. Capillary density was increased, and necrosis was reduced in the CGA-treated rats. Chlorogenic acid decreased malondialdehyde levels as well as increased reduced glutathione and superoxide dismutase levels in the flap tissues. This study showed that CGA significantly improved flap survival by its antioxidant activities with intra-arterial local injections.

Summary Introduction As a technique of anastomosis for vessels of less than 0.8 mm in diameter, supermicrosurgery has aroused renewed interest on account of its potential clinical applications. The technical difficulty of surgery at such a small scale necessitates exploration of new methods likely to render the anastomoses accessible and reliable. The aim of this article is to present the results of an experimental study on the feasibility of anastomoses (arterial diameter ≤ 0.5 mm), assisted by the injection of hyaluronic acid (HA). Materials and methods Ten end-to-end arterial anastomoses of the inferior epigastric artery (diameter ≤ 0.5 mm) were performed in 5 rats. An injection of HA had previously been carried out in the vessel lumen and the sutures were made with 12–0 nylon. Immediate and 3-day permeability were controlled and anastomosis times were measured. Results Average diameter of the arteries was 0.42 mm (range 0.29–0.48 mm). Mean anastomosis duration was 19.5 min (range 15–23 min). The average number of stitches was 6. Immediate patency was 100% with a success rate of 80% at 3 days. Conclusions The properties of HA seem to effectively facilitate anastomoses of arteries with a diameter ≤ 0.5 mm. HA provides comfort and promotes safety in performance of exceedingly small-scale surgery. While the results appear promising, but further studies are needed in order to determine the potential toxicity of this method on tissues.

A new type of flap, the perforator-based flap, has been described in the last decade. It has been used successfully as a pedicle or free flap by many plastic surgeons. There is no animal model for research, although these flaps have gained popularity in clinical use. We created a perforator-based flap model in the rat (a perforator-based flap group and two control groups; 10 rats in each group) and evaluated the survival characteristics of the new flap. The abdominal skin flap was elevated based on the second perforator of the right superior deep epigastric artery and then sutured to its original bed. In the first control group, the same flap was elevated with a subcutaneous pedicle without any perforator; in the second control group, a right-sided, random-pattern pedicle abdominal skin flap with the same dimensions and location was elevated and sutured to its original bed. Flap survival was studied, and microangiography and histologic studies were performed. The amount of viable skin in the three groups was compared 1 week later. The area of surviving skin paddles in the experimental group ranged from 74 to 83 percent; in the first control group, it was 0 percent; and in the second control group, it ranged from 29 to 44 percent (p < 0.001 and p < 0.001, respectively). There was a predictable and constant area of necrosis in the model. The results of this study demonstrate that most of the abdominal skin of the rat can survive on the basis of a single musculocutaneous perforator vessel. This flap can be easily elevated, and it can be used as a reliable model for flap research.

Background Laparoscopic techniques are responsible for a new set of complications. Their causes, incidence and outcome must be evaluated. New complications of laparoscopic technique in biliary surgery are generally due to lack of training and experience, over-confidence, and errors in technique. Method The records of 2000 successive elective laparoscopic cholecystectomies (LC) were reviewed to evaluate the incidence of complications due to the laparoscopic technique. Results Haemorrhage at the trocar insertion site was recorded in 14 patients. In one patient the epigastric artery was severed and the operation was converted to an open cholecystectomy (OC). In one patient who had undergone a previous laparoscopy, the small bowel was injured and sutured during open laparoscopic access. In 25 patients stones were lost in the peritoneal cavity. Three of them developed intra-abdominal or abdominal-wall abscess due to the stones. Monopolar diathermy was responsible for one colonic perforation and one bile-duct perforation. Discussion Blind introduction of pneumoperitoneum needles and trocars, poor visualisation, excessive use of diathermy, errors in surgical technique and over-confidence are causes of serious complications.

The experiments were designed to elucidate the mechanism of thiopentone-induced inhibition of contractile responses in isolated human epigastric arteries. Segments of human epigastric arteries were obtained from patients who underwent elective or emergency caesarean section, placed in standard physiological salt solution (PSS), cut into rings at 3 mm intervals and suspended in organ baths for recording of isometric contractions at 37 degrees C, and pH 7.4. Three protocols were employed to examine the inhibitory effect of thiopentone: (a) concentration-dependent effect on 10(-7) M noradrenaline (NA)- or high-K+ (40 mM)-induced contractions: (b) effect on NA-induced extra-and intracellular Ca(2+)-dependent contractions and (c) effect on the dose-response curve when Ca2+ is restored to Ca(2+)-depleted rings in Ca(2+)-free 40 mM K(+)-depolarizing medium. Thiopentone (1 x 10(-6) -4 x 10(-3) M) caused concentration-dependent relaxation of both NA- and high-K(+)-induced contractions. The magnitudes of both precontractions were not significantly different but the IC50 values for thiopentone relaxation of high-K+ contractions were significantly lower than for NA contractions. Thiopentone (10(-4) M) significantly attenuated the phasic (intracellular Ca2+ dependent) contractile responses to 10(-5) M NA in Ca(2+)-free PSS as well as the tonic (extracellular Ca2+ dependent) contractions upon restoration of Ca2+. In contrast, nifedipine (1 microM) did not modify the phasic response but significantly attenuated the tonic response. Thiopentone (10(-4) M) also almost completely abolished concentration-dependent Ca(2+)-induced contractions in K(+)-depolarized Ca(2+)-depleted rings. The results suggest that in the smooth muscle of human epigastric arteries, thiopentone-induced relaxation is non-specific and is associated with impairment of Ca2+ supply from both extracellular and intracellular pools.

A model of angiogenesis has been developed in the rat. The epigastric vascular pedicle was exposed in the groin, a 7 mm segment of epigastric artery was excised leaving the vein intact and, after a variable period of time for angiogenesis to occur between the ends of the artery, a skin flap was elevated on the epigastric vascular pedicle so that it depended completely for its blood supply on bridging angiogenesis across the created gap. Skin flap survival and vessel counts were measured as indices of the angiogenic response. In this model we observed a spontaneous increase in vessel counts between the ends of the artery, and a corresponding increase in skin flap tissue survival until day 10 after which time vessel counts plateaued whilst tissue survival continued to increase until day 14. In the angiogenic pedicle, a time-dependent development of granulation tissue containing numerous macrophages and mast cells, and capillary sprouting were documented. When flap elevation was performed 7 days after arterial excision skin flap survival was 42%. Thus, in this model, 7 days is a suitable interval for the future evaluation of the effects of either pro- or anti-angiogenic agents.

Based on earlier observations that the thickness of the intima and structure of the media may have an impact on the long-term patency of arterial conduits and the lack of detailed histologic studies of the right gastroepiploic and inferior epigastric arteries, we subjected both vessels to morphometric analysis with emphasis on their suitability as conduits in myocardial revascularization.The right gastroepiploic and inferior epigastric arteries were harvested from 28 unselected individuals (mean age, 73.2 years) at autopsy, and the luminal diameter and the width of the intima and media were measured.At all levels of measurement (origin, 10 cm, and 15 cm), the luminal diameter of the inferior epigastric artery was significantly smaller than that of the right gastroepiploic artery (p0.05). The right gastroepiploic artery demonstrated only mild intimal hyperplasia. In contrast, the inferior epigastric artery showed substantial intimal hyperplasia within the first 1-cm segment (mean, 134 +/- 131 microns versus 50 +/- 49 microns for the corresponding segment of the right gastroepiploic artery; p = 0.01). Intimal hyperplasia was only mild in the remainder of the inferior epigastric artery. In both vessels, the media was muscular with rare dispersed elastic fibers. The mean thickness of the media ranged from 380 +/- 116 microns proximally to 155 +/- 70 microns distally for the right gastroepiploic artery, and from 316 +/- 86 to 165 +/- 70 microns, respectively, for the inferior epigastric artery.In myocardial revascularization, use of the right gastroepiploic artery may generally be preferable to use of the inferior epigastric artery. This recommendation is based on the larger luminal diameter of the right gastroepiploic artery as compared with the inferior epigastric artery, the significantly greater intimal hyperplasia in the first segment of the inferior epigastric artery, and the limitation that the inferior epigastric artery can be used only as a free graft. The rate of development of intimal hyperplasia in the right gastroepiploic artery, if used as an in situ coronary artery bypass graft, may be slow, approximating that of the right gastroepiploic artery in its natural environment.

At the Cleveland Clinic Foundation, RN first assistants (RNFAs) have replaced inexperienced interns and rotating general surgery residents as surgical first assistants. Their new role includes harvesting inferior epigastric arteries (IEAs) for coronary artery bypass procedures. The RNFAs remove the IEAs through paramedian incisions that extend from below the umbilicus to the groin, dissect the IEAs as pedicles, and complete wound closure. This is one example of the expanded role of RNFAs during complex surgical procedures.

A 36-year-old lady was admitted to the hospital because of acute appendicitis. A laparoscopic appendicetomy was converted to a MacBurney approach because of a difficult bleeding van de appendicular artery. After closure, patient went into hypovolemic shock.

In order to test methods of predicting skin flap viability, a skin flap model in Sprague-Dawley rats was established. As criteria for studying skin flap survival, we compared measurement of skin pH, temperature, as well as fluorescence photography and computer aided digital morphometry (CADM). Ninety male Sprague-Dawley rats were divided into three groups in which pedicles were clamped for 10, 15, or 20 h. A standardized bipedicled skin flap was prepared, maintained by the epigastric artery, vein and nerve. All flaps were sutured back in place immediately after clamping. We found that postoperative prediction of flap survival based solely upon external appearance was impossible until the 2nd postoperative day. Changes in pH were not statistically significant in the prediction of vital or necrotic flaps. The temperature measurements showed, that in the event of viability the decrease in flap temperature versus the reference temperature (rectal temperature) was significant (P < 0.0094 in Group II, 15 h of ischaemia) or at least a tendency to significance (P < 0.059 in Group III, 10 h of ischaemia) bigger than in the event of partial or total flap necrosis. The photographic documentation using fluorescein showed that all coloured areas survived. Group I (20 h) showed predominantly total flap necrosis. Most flaps in Group III (10 h) exhibited a small necrotic area at the tip. In Group II (15 h) no typical staining pattern could be observed. Furthermore, computer aided digital morphometry demonstrated a decrease of the necrotic area by 7% between the 2nd and 4th postoperative day in Groups II and III. The method which gave the most exact prediction about viability was the fluorescein staining of the flaps via the tail vein.

The purpose of this study was to define the arterial vascular anatomy of the tendinous intersections of the rectus abdominis muscle through anatomic dissection and perforator mapping. In 14 fresh cadavers, the deep inferior epigastric arteries were injected with blue latex. In 7 specimens (14 rectus abdominis muscles), dissection of each tendinous intersection was performed under loupe magnification. In the other 7 specimens (10 rectus abdominis muscles), perforator mapping was performed at each intersection relative to the rest of the rectus abdominis muscle. In 2 additional cadavers, radiographs were taken of barium-latex-injected specimens. We found that the vascular architecture of the intersections is characterized by transverse arcades arising from either the superior or inferior epigastric arteries, which send branches supplying muscle or the overlying skin. There is a higher number of perforators per square centimeter originating in the intersections than in the rest of the rectus abdominis muscle. To obtain optimal vascular supply, the design of transverse rectus abdominis flaps may be based on intersection location as well as paraumbilical location.

Concomitant coronary artery disease (CAD) and Leriche’s syndrome is clinical scenario which poses a challenge to cardiovascular surgeons. This report describes a case of arterial myocardial revascularization in a patient with CAD and Leriche’s syndrome by means of right internal thoracic artery harvested with right epigastric artery in situ fashion, performed in addition to simultaneous aorto-bifemoral bypass.

As our knowledge of the origin of the cutaneous circulation becomes more precise, many preconceived notions continue to be abandoned. In this context, the general rule that distally based flaps are inherently inferior to proximally based flaps also should appropriately be challenged. To disprove this long-standing dictum, multiple abdominal flaps were simultaneously elevated in 15 Sprague-Dawley rats that included or excluded all possible combinations of musculocutaneous or axial skin perforators from each major source vessel (cranial or caudal epigastrics, superficial epigastric or lateral thoracic, respectively). These flaps were sequenced randomly in each rat to have superior (proximal) or inferior (distal) pedicles such that at least five flaps of each subtype were analyzed. Mean flap survival when the specific source vessel was retained uniformly was significantly greater than in all flaps where the source vessel had been excluded regardless of the orientation of the flap pedicle. All flaps with intact circulation had no significant difference in mean flap survival. Similarly, when normal flap circulation was excluded, no difference was observed in mean flap survival. Again, both these observations were true irrespective of the location of the flap base. Thus the major factor in determining flap viability was not whether its pedicle was proximally or distally based but rather the origin and quality of its intrinsic blood supply.

The objective of this work is to evaluate the significance of finding reversal of flow in the inferior epigastric artery during noninvasive assessment of the lower extremity circulation using Doppler ultrasonography. This phenomenon is easy to demonstrate when present and predicts aortic or iliac artery stenosis or occlusion at subsequent arteriography. We found collateralization to the leg from the ipsilateral internal mammary artery via the epigastric arteries in all cases in which ultrasonography showed such reversal and these vessels carried the majority of the blood supply to the leg. This finding and its significance should be conveyed to patients and their physicians so that deliberate harvesting or inadvertent surgical damage to the epigastric arteries can be avoided, as this has been shown to lead to worsening of leg ischemia.

We present the case of a patient who underwent a seemingly uneventful laparoscopic colposuspension. She appeared to bleed from one of the laparoscopic ports postoperatively and her haemoglobin level dropped. She became unwell on the eighth postoperative day. A diagnosis of small bowel obstruction was made from a plain X-ray film and the cause of this was revealed only at laparotomy. This case highlights a previously unreported cause of small bowel obstruction secondary to haematoma.

Classical descriptions of tumor physiology suggest two origins for tumor hypoxia; steady-state (diffusion-limited) hypoxia and cycling (perfusion-modulated) hypoxia. Both origins, primarily studied and characterized in murine models, predict relatively small, isolated foci or thin shells of hypoxic tissue interspersed with contrasting oxic tissue. These foci or shells would not be expected to scale with overall tumor size since the oxygen diffusion distance (determined by oxygen permeability and tissue oxygen consumption rate) is not known to vary dramatically from tumor to tumor. We have identified much larger (macroscopic) regions of hypoxia in rat gliosarcoma tumors and in larger human tumors (notably sarcomas and high-grade glial tumors), as indicated by biochemical binding of the hypoxia marker, EF5. Thus, we considered an alternative cause of tumor hypoxia related to a phenomenon first observed in window-chamber tumor models: namely longitudinal arteriole gradients. Although longitudinal arteriole gradients, as originally described, are also microscopic in nature, it is possible for them to scale with tumor size if tumor blood flow is organized in an appropriate manner. In this organization, inflowing blood would arise from relatively well-oxygenated sources and would branch and then coalesce to poorly-oxygenated outflowing blood over distances much larger than the length of conventional arterioles (multi-millimeter scale). This novel concept differs from the common characterization of tumor blood flow as disorganized and/or chaotic. The organization of blood flow to produce extended longitudinal gradients and macroscopic regional hypoxia has many important implications for the imaging, therapy and biological properties of tumors. Herein, we report the first experimental evidence for such blood flow, using rat 9L gliosarcoma tumors grown on the epigastric artery/vein pair.

The superficial inferior epigastric artery (SIEA) flap is an excellent option for free tissue transfer breast reconstruction. Similar to the free transverse rectus myocutaneous (TRAM) and deep inferior epigastric perforator (DIEP) flaps, the SIEA pedicle supplies the fasciocutaneous tissues of the lower abdomen. The SIEA flap does not involve removal of or potential damage to the rectus muscles. Nonetheless, the vascular pedicle may be a challenge to dissect and variable in its presence and caliber. This article presents a case report and an extended delay technique to augment the SIEA system in a patient with prior bilateral deep inferior epigastric artery ligation.

Rectus sheath haematoma (RSH) is an uncommon condition caused by lesion of the superior or inferior epigastric arteries or their branches or by rupture of the rectus muscle. Treatment is usually supportive; however, if haemodynamic compromise develops, intravascular embolisation or surgery may be required. Furthermore, in some cases, bleeding may be so conspicuous that it can determine the patient's death before an adequate treatment is performed. We performed a retrospective study on 78 consecutive patients with the diagnosis of RSH admitted to the General Surgery Unit of our hospital between January 2000 and December 2010 in order to identify possible prognostic risk factors that could affect the operational approach before the onset of haemodynamic instability.Demographic characteristics, patient history, laboratory and diagnostic imaging examinations were investigated. The variables considered were: gender, age, anti-coagulation or anti-platelet therapy, trauma, international normalised ratio (INR) and bleeding time in the first 72 h of observation and concomitant diseases. The data were used for statistical analysis.Sixty patients received a conservative treatment, while 18 underwent operative treatment for haemodynamic instability (embolisation in 2 patients and surgery in 16 patients). Three of these 18 patients (17 %) died for consumption coagulopathy after surgery. None of the variables included in the univariate statistical analysis was significant (p = ns).Ultrasonography or computed tomography are the most common methods used to establish the diagnosis of RSH, so it is no longer a diagnostic dilemma. Most patients can be treated conservatively and an operative treatment is justified only in case of haemodynamic instability. Our retrospective study could not identify any prognostic risk factor of haemodynamic instability in RSH. We believe that only a close observation of the patients with RSH and "common sense" can prevent a possible fatal outcome.

Breast reconstruction using the deep inferior epigastric perforator (DIEP) flap is becoming more common and can help reduce donor site morbidity. The authors proposed that dissection of the deep inferior epigastric artery (DIEA) and vein (DIEV) to their external iliac source may not be required for safe flap transfer.Sixteen whole fresh cadaveric hemiabdomens were used to dissect transverse abdominal-based flaps. Latex injection of the DIEA system was carried out, and the diameters of the DIEA/DIEV vessels were assessed at various points along the course of the pedicle from the origin to the perforator. A clinical study of 26 patients who underwent a short and ultrashort pedicle DIEP flaps was carried out.The average DIEA and DIEV vessel diameters were relatively similar from the external iliac origin to a point just caudal to the bifurcation. At the lateral rectus edge, the average DIEA diameter was 3.2 mm, and the DIEV diameter was 3.1 mm. The average pedicle length obtained with classic DIEP dissection was 16.9 cm, short-pedicle DIEP dissection 10.4 cm, ultrashort technique 8.1 cm, and free TRAM technique 6.5 cm. Venous injection study demonstrated rich venous interconnections between both venae comitantes. In their clinical study, the authors were able to achieve average pedicle lengths of 11.0 cm when transecting cranial to the lateral edge of the rectus, with average diameters of 2.5 mm (artery) and 2.9 mm (vein).Transection of the DIEA/DIEV pedicle at the lateral rectus edge or more proximally is safe and can help reduce operative time and donor-site morbidity.Therapeutic, IV.

SummaryThe cranial rectus abdominus muscle pedicle flap (CRAMP) group did not demonstrate any significant difference in perfusion compared to the control rectus abdominus muscle flap group with the caudal epigastric artery intact. Angiography of the cranial epigastric artery demonstrated anastomoses with the caudal epigastric artery.This study evaluated the angio-gram of the cranial epigastric artery and perfusion of the cranial rectus abdominus muscle pedicle (CRAMP) flap using scintigraphy. The results indicated the CRAMP flap may remain viable in a chronic model.

The classical DIEP-flap is considered state-of-the-art in microsurgical autologous breast reconstruction. Some patients may require additional volume to match the contralateral breast. This quality control study prospectively evaluates the feasibility and outcome of a surgical technique, which pursues the volumetric augmentation of the DIEP-flap by harvesting of additional subscarpal fat tissue cranial to the classical flap border.For radiologically based estimation of volumetric flap-gain potential, abdominal CT-scans of 10 Patients were randomly selected and used for computerized volumetric estimates. Surgical evaluation of the technique was prospectively performed between 09/2009 and 09/2010 in 10 patients undergoing breast reconstruction with extended DIEP-flap at two institutions. The outcome regarding size, volume, and symmetry was evaluated.Radiologically, the mean computed volume gain of an extended DIEP was 16.7%, when compared with the infraumbilical unilateral flap volume. Clinically, the intraoperatively measured mean volume gain was of 98.6 g (range: 75-121 g), representing 13.8% of the flap volume. All 10 flaps survived without revision surgery. In three flaps, minor fat necrosis occurred in zone III and was treated conservatively. No fat necrosis was observed in the extended flap area.In this first prospective series, the extended DIEP-flap proved to be feasible, reliable and safe for its use in breast reconstruction. Both radiological estimation and intraoperative measurements demonstrated a statistically significant volume gain with no complications in the extended area. The technique is of benefit in selected patients requiring additional reconstructive volume than the one achieved with the classical DIEP-flap.Therapeutic Level IV.

The blood supply of microvascular free flaps is rated as very critical, particularly in the first postoperative days. Only a timely recognition of a complication and its treatment can ensure the survival of the flap. To quantify the postoperative perfusion dynamics, we measured the oxygen supply and blood flow of the deep inferior epigastric perforator (DIEP) flaps.A total of 23 patients undergoing DIEP flap breast reconstruction were involved in this study. Noninvasive measurements were performed with the O2C-device, which combines the determination of hemoglobin oxygenation and blood flow using white light and laser light. The first measurement was performed immediately after the flap anastomosis. Further measurements were carried out on the first, third, fifth, and seventh postoperative days.The preoperative value represents our baseline. With the exception of the third day, all postoperative measurements were above the baseline. On the third postoperative day, there was a decrease in the cutaneous oxygen saturation of 22% and a decrease in blood flow of 18% on average, regardless of the individual fluctuations of patient's blood pressure.The postoperative perfusion characteristics of the DIEP flap showed a critical drop in the cutaneous oxygen supply and blood flow on the third postoperative day. This represents a potential risk and should be considered in the postoperative management of the DIEP flap.

Breast reconstruction continues to evolve. The deep inferior epigastric perforator (DIEP) flap is a well-described means of providing natural tissue reconstruction with an attendant goal of minimizing damage in the abdominal donor site.For patients with the need for autogenous reconstruction of a single breast and insufficient abdominal fatty volume for routine DIEP flap reconstruction, the authors present an option that allows for incorporation of the entire abdominal fatty composite with sequential linkage and stacked inset of two individual abdominal flaps. The ability to take advantage of the entirety of the abdominal donor volume allows those with a relatively thin body habitus to enjoy candidacy for DIEP flap reconstruction. This sophisticated microsurgical procedure overcomes some of the limitations of other techniques with similar goals such as the bipedicled transverse rectus abdominis musculocutaneous flap by avoiding muscle sacrifice and allowing precise, independent flap inset. The authors describe their experience with this technique in 55 patients with 110 flaps over 3 years.The authors' experience reviews the use of the stacked DIEP flap in a large number of patients with high success rates and superb aesthetic outcomes over a relatively short period of time. Of the 55 patients who underwent reconstruction, all enjoyed successful outcomes. Patient satisfaction was high in the studied population.Stacked DIEP free flap breast reconstruction is a reproducible, safe, and innovative yet technically demanding solution for patients seeking autogenous breast reconstruction with otherwise inadequate abdominal fatty volume.

From March 1990 through January 1992, 108 patients undergoing myocardial revascularization had one (91) or both (17) inferior epigastric arteries (IEA) used for myocardial revascularization. The internal thoracic artery (ITA) was used bilaterally in 87 patients. Of the 373 distal anastomoses, 210 (56%) were with the ITA, 130 (35%) with the IEA, and 12 (3%) with the gastroepiploic artery. Nineteen patients (18%) received 21 saphenous veins. When compared with the ITA, the IEA demonstrated a longer harvest time (36.5 vs 29.6 min, P0.0001), a shorter usable length (11.9 cm vs 16.5 cm, P0.001), and similar flow (49.7 cc/min vs 48.7 cc/min, P = NS). The operative mortality was 2.8%. Two deaths resulted from low cardiac output and the one remaining death from complications of a cerebral vascular accident. The most common major complication was respiratory insufficiency, which occurred in 11 patients (12%). There were two sternal infections (2%), and two abdominal wound infections (2%), none of which were fatal. The IEA is an acceptable additional arterial conduit. It can be safely employed with one or both ITAs. Short-term and long-term patency must be established before preferential use of this conduit is advised.

A 62-year-old man presented with an extensive defect of the scrotum caused by Fournier's gangrene. We reconstructed the scrotum using a thinned flap based on both inferior epigastric arteries one month after the first debridement. This method has the advantage of achieving adequate mobility of the reconstructed scrotum. The results were satisfactory both functionally and cosmetically, although we had to repair a hernia at the donor site a year later.

Morbidity after converting failed laparoscopic adjustable gastric banding (LAGB) to laparoscopic Roux-en-Y gastric bypass (LRYGB) is three- to fivefold higher than after primary LRYGB. Allowing a time interval between band removal and actual gastric bypass might reduce local inflammation and reduce morbidity. This study is a retrospective single-center study of patients who needed conversion to LRYGB because of failed LAGB. Outcomes after conversion of LAGB to LRYGB in one or two steps were compared. Between October 2008 and June 2010, 23 patients had a conversion in one step (group A) while, in 14 patients, the conversion was carried out at least 2 months after band removal (group B). The mean duration of surgery in group A was 150 ± 39 min while it took 181 ± 39 min to complete both steps in group B (p = 0.02). Length of stay in group A was 3 (3–8) days, but was 5 (4–8) days for the two steps in group B (p = 0.004). During a follow-up of 6–23 months, one pulmonary embolism, one epigastric artery bleeding, and three anastomotic strictures occurred in group A, while no complications were observed in group B. The BMI dropped from 41.4 ± 6.7 to 28.7 ± 10.8 kg/m2 in group A and from 43.8 ± 5.8 to 35.3 ± 7.55 kg/m2 in group B. Operating time and hospital stay are increased when conversion is performed in two steps, but, in this small series, this strategy decreased morbidity and more specifically the rate of anastomotic strictures.

Elevation of the deep inferior epigastric perforator (DIEP) flap interrupts its superficial venous system, and if drainage through the deep venous system is inadequate the flap may develop congestion. The purpose of this retrospective study was to determine the fate of the congested DIEP flap and to optimize the strategy for its salvage.Thirty-two of 162 patients who underwent unilateral breast reconstruction with a DIEP flap developed venous congestion. For the purpose of outcome analysis, cases were retrospectively allocated to "observation-only" (group A, n = 11), postoperative salvage (group B, n = 7), and intraoperative salvage (group C, n = 14), and complications among the various groups were compared to determine the necessity and optimal timing of salvage intervention.Two flaps (1 in group A, another in group B) failed completely, giving a success rate 98.8%. The complication rate and hospital stay were significantly lower in group C than in group B (P = 0.03, P = 0.02). The rate of venous congestion requiring salvage procedures was 13%, with a salvage rate of 95%. Salvage procedures included venous augmentation with an additional recipient vein in 7 procedures, adding superficial inferior epigastric vein (SIEV) to DIEV in 11 procedures, and substituting with SIEV in 7 procedures. There was no statistical difference in flap salvage rate using the SIEV between "augmentation" and "substitution."The salvage procedures for venous compromised DIEP flap are better performed intraoperatively rather than postoperatively to prevent further complications. The engorged SIEV could be incorporated by anastomosing to an additional recipient vein or adding to the DIEV-internal mammary vein axis or substituting for DIEV.

To evaluate the accuracy of multidetector computed tomographic (CT) angiography versus color Doppler ultrasonography (US) for perforating artery identification, intramuscular course of perforator vessel assessment, and superficial venous communication detection before a deep inferior epigastric perforator (DIEP) procedure for breast reconstruction.Informed consent and institutional review board approval were obtained. Forty-five patients underwent multidetector CT angiography and color Doppler US to identify the DIEP vessel prior to breast reconstruction surgery. Findings at surgery were used as a reference for accuracy evaluations.The accuracy for identifying dominant perforator arteries was 97% for color Doppler US and 91% for CT angiography. Perforator arteries suitable for surgery were identified in 90% of cases with color Doppler US and in 95% of cases with CT angiography. For measurement of perforator calibers, surgical findings were similar to color Doppler US measurements (P = .33) but were significantly different than CT measurements (P.0001). The accuracies for intramuscular course of perforator vessel assessment and superficial venous communication detection were 95% and 97% for CT and 84% and 80% for color Doppler US, respectively. In our population, the absence of superficial venous communication was associated with a risk for flap morbidity (P = .009).Both color Doppler US and CT angiography resulted in accurate DIEP mapping. Color Doppler US was superior for measuring perforator artery calibers, and CT angiography was superior for estimating the intramuscular course of the perforator vessel and identifying superficial venous communications. Considering x-ray exposure and results of this study, employing multidetector CT angiography is suggested only in selected cases.

A free paraumbilical perforator-based flap fed by a muscle perforator from the inferior deep epigastric artery and with no muscle was used in 13 patients. Among them, a free thin paraumbilical perforator-based flap with a thin layer of fat, to protect the subdermal plexus of the vessels, was used in seven patients. The dominant pedicle perforator of this thin flap is usually located around the umbilicus and a large flap can be obtained. Its critical length-to-breath ratio is considered to be 4:3. The advantages of this flap are a long and large vascular pedicle, rare postoperative abdominal herniation, little bulkiness of the flap, and a relatively large skin territory. The disadvantages are technical difficulties in dissection of the perforator and anatomical variation in the location of the perforator. We believe this flap largely overcomes the problems of the conventional rectus abdominis musculocutaneous flap.

Venous flaps have several potential advantages over traditional flaps, but their uses have been limited by unpredictable survival. Although clinical and experimental studies have concentrated mainly on the antegrade arterialization of venous flaps to increase survival, retrogradely arterialized venous flaps (AVFs) may have the greatest potential. There is, however, little literature on their use. There are also no animal studies comparing their survival to other venous flaps used in a similar situation. Our aim was to design a flap utilizing the rabbit's valved, thoracoepigastric vein (consisting of the lateral thoracic and epigastric veins) as the source vessel for the study of retrograde arterialized venous flaps (RAVFs). A pilot study (n = 10) to determine the survival of RAVFs was performed utilizing this animal model. Four flaps had complete survival at the end of our 2-week observational period. However, we also had four partial flap losses and two cases in which the entire flap was lost. An average survival area of 44.5% was observed. In conclusion, our designed rabbit thoracoepigastric RAVF is simple to apply and easily reproducible. It is the first animal flap adapted specifically for the study of RAVFs, and may be used for the further investigation of these flaps, which have shown unpredictable survival to date.

The radiation exposure of Computed Tomographic Angiography (CTA) in DIEP flap planning : low dose but high impact