Download Anterior Intercostal Artery Perforator Flap Autologous Augmentation

COSMETIC
Anterior Intercostal Artery Perforator Flap
Autologous Augmentation in Bariatric Mastopexy
Paolo Persichetti, M.D., Ph.D.
Stefania Tenna, M.D., Ph.D.
Beniamino Brunetti, M.D.
Achille Aveta, M.D.
Francesco Segreto, M.D.
Giovanni Francesco Marangi,
M.D.
Rome, Italy
Background: Breast reshaping after massive weight loss represents a challenging procedure because of severe hypoplasia and tissue ptosis. Standard mastopexy techniques are often inadequate to restore a pleasant profile and volume.
The authors present their experience with the anterior intercostal artery perforator flap in breast autologous augmentation and remodeling.
Methods: Fifteen bariatric patients (30 breasts) affected by severe breast ptosis
and tissue laxity in the upper abdominal wall underwent superior pedicle
mastopexy with anterior intercostal artery perforator flap autologous augmentation. The flap was harvested including soft tissues above and below the inframammary fold, extending cranially 5 to 6 cm above the fold and inferiorly
over the costal cage and hypochondrium. The flap was completely islanded on
intercostal perforators originating from the fifth to seventh intercostal spaces.
It was cranially advanced and sutured to the pectoralis major fascia. The medial
and lateral borders were sutured together to shape an “autologous implant.”
Results: All of the flaps were transferred successfully. The donor site was always
closed primarily and upper abdominal laxity corrected. All of the breasts presented
soft at palpation, with no clinical signs of flap necrosis early or late postoperatively.
At 1-year follow-up, the breasts maintained good shape and projection.
Conclusions: The anterior intercostal artery perforator flap proved to be a
reliable option in bariatric mastopexy. The technique can be performed easily
and allows the harvesting of a large amount of tissue with a wide range of motion,
providing adequate breast volume and projection without the need for implant
placement. (Plast. Reconstr. Surg. 130: 917, 2012.)
CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.
T
he number of bariatric surgery procedures
has increased constantly over the past
decade.1 Although they may solve the excess
weight and many of its associated comorbidities,
the patient is left with excess skin and soft tissue,
often leading to referral to the plastic surgeon.
The breast profile may be severely distorted as a
consequence of massive weight loss, with upper
pole deficiency, high-grade ptosis, and lowered
inframammary fold. In these patients, mastopexy
is challenging, traditional techniques are often
inadequate because of poor quality of tissues, and
restoration of breast volume is a main issue for a
pleasant morphology. The thin overstretched dermis and the poor subcutaneous tissue make implant placement alone unadvisable. Colwell and
From the Plastic and Reconstructive Surgery Unit, Campus
Bio-Medico di Roma University.
Received for publication January 25, 2012; accepted April
19, 2012.
Copyright ©2012 by the American Society of Plastic Surgeons
DOI: 10.1097/PRS.0b013e318262f38a
colleagues2 already described the use of cadaveric
dermis (AlloDerm; LifeCell Corp., Branchburg,
N.J.) to supplement suspension of the breast and
the implant in an anatomical position, but the
ideal volume restoration in this scenario is repre-
Disclosure: The authors have no financial interest
or commercial association with the subject matter or
products mentioned in this article. No funding was
received for this work.
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Plastic and Reconstructive Surgery • October 2012
sented by the use of autologous tissues. Some flaps
such as the rotation-advancement of the superomedial pedicle described by Losken and Holtz3 or
the use of composite tissues nourished by intercostal perforators have been proposed. Starting
from Kerrigan and Daniel,4 several studies investigated the anatomy of perforators originating
from intercostal arteries.5,6 Pedicled and free flaps
nourished by these vessels have been described for
hand,5 breast, and trunk reconstruction.7 In particular, the use of intercostal artery perforator
flaps nourished by lateral branches of the intercostal system (lateral intercostal artery perforator
flap) has been previously reported in postbariatric
patients. The authors report their experience with
the anterior intercostal artery perforator flap,
based on anterior intercostal perforator branches
originating from the fifth to seventh intercostal
spaces, in the field of postbariatric autologous augmentation mastopexy.
MATERIALS AND METHODS
Cadaveric Study
In our preclinical phase, cadaveric studies
were performed to evaluate the viability of the
technique, focusing on localization of the perforators and range of motion of the flap. A large skin
paddle above and below the inframammary fold
was dissected to identify the number and course of
the main perforators emerging from the pectoralis major, serratus anterior, and rectus abdominis
muscle fascia. On average, two or three musculocutaneous perforators for each intercostal space
were found (Fig. 1). Flap dimensions ranged from
6 to 12 cm in width and 6 to 20 cm in length,
depending on upper abdomen laxity. Range of
motion of the flap was also assessed and was 3 to
5 cm. The greatest advancement has been
achieved by sacrificing the most caudal perforators. [See Figure, Supplemental Digital Content 1,
which shows a cadaveric study, http://links.lww.
com/PRS/A539. (Left) Mobility of the flap. (Right)
Increased range of motion after sacrifice of the
most caudal perforators.]
Flap Design and Operative Technique
Preoperative marking of inverted-T superior
pedicle mastopexy8 is planned. A pinch test of the
upper abdominal wall, in supine and orthostatic
positions, has to be performed to quantify the
amount of skin laxity. The position and number of
cutaneous intercostal perforators is identified by a
hand-held Doppler probe above and below the
inframammary fold, and then the anterior inter-
918
Fig. 1. Cadaveric study. (Above) Two or three perforators for
each intercostal space have been isolated. (Below) Perforators
emerging from the pectoralis major muscle fascia.
costal artery perforator flap is drawn (Fig. 2). Flap
dimensions usually extend cranially until the
lower margin of the areola (at least 5 to 6 cm above
the fold), and inferiorly 5 to 10 cm below the
inframammary fold, according to upper abdominal skin laxity that needs to be corrected and always checking manually for feasibility of primary
closure. Flap harvesting is performed in supine
position using 2.5⫻ loupe magnification: the superior portion of the flap is first dissected craniocaudally along and pectoralis major fascia; then,
inferiorly, the flap is undermined following a
plane superficial to the serratus anterior and rectus abdominis muscles fasciae. Major intercostal
perforators emerging through the pectoralis major, serratus anterior, and rectus abdominis muscles are isolated. The anterior intercostal artery
perforator flap is islanded on perforator vessels
Volume 130, Number 4 • Remodeling after Bariatric Mastopexy
Fig. 2. Preoperative markings after Doppler mapping.
from the fifth to seventh intercostal spaces, and all
of the perforators are initially spared without skeletonizing them through the muscle (Fig. 3). Mobility of the flap is then evaluated. Perforators
from the seventh space can be sacrificed to enhance cranial advancement and avoid their compression by primary closure of the donor site. Minor lateral vessels may also be cut to obtain a better
breast reshaping (Fig. 4). After careful evaluation
of vascularity, the flap is decorticated. The superior border is anchored to the pectoralis major
fascia (Fig. 5, left), and the medial and lateral
borders are flipped and sutured to each other in
a round shape fashion. The “autoimplant” is stabilized to the pectoralis major fascia with absorbable sutures to prevent shearing forces on the
perforators (Fig. 5, right). (See Figure, Supplemental Digital Content 2, which shows the surgical
technique, http://links.lww.com/PRS/A540. Medial
and lateral borders of the anterior intercostal artery perforator flap are sutured to model an autoprosthesis.) Breast shape and projection are
checked and abdominal subcutaneous tissue is undermined to achieve primary closure of the donor
site, as in a reverse abdominoplasty. The superficialis fascia must be fixed to rib periosteum with
nonabsorbable stitches to redefine the inframammary fold in the position planned during the preoperative drawing. Mastopexy is then completed
with the patient sitting: the breast is sutured
around the “autologous implant” as in a standard
inverted-T superior pedicle technique. (See Figure, Supplemental Digital Content 3, which shows
an intraoperative view of the breast sutured over
the anterior intercostal artery perforator flap in a
standard inverted-T technique, http://links.lww.
com/PRS/A541.) Suction drains are placed for
each side and kept for at least 48 hours.
Fig. 3. Anterior intercostal perforators. Adequate mobility of the
flap is achieved without skeletonizing perforators through the
muscle.
Patient Population
Fifteen bariatric patients (30 breasts) underwent anterior intercostal artery perforator flap autologous augmentation combined with inverted
T-mastopexy at the Department of Plastic, Reconstructive, and Aesthetic Surgery of “Campus BioMedico di Rome” University from March of 2010
to April of 2011 (Table 1). In eight patients, the
severe breast ptosis was associated with significant
skin laxity in the upper abdominal wall. The mean
age of the patients was 40.3 years and the average
body mass index was 32.7. Sleeve gastrectomy had
been performed in four patients, biliopancreatic
diversion had been performed in nine patients,
transoral gastroplasty had been performed in one
patient, and gastric bypass had been performed in
one patient. The average weight loss was 45 kg, and
the average suprasternal notch–to–nipple distance was 28.9 cm. All of the patients had stable
weight control within the previous 6 months. No
other surgical procedure was performed at the
same time. Follow-up ranged from 6 to 12 months.
RESULTS
All of the flaps were transferred successfully.
The mean size of the flaps was approximately 8.8
⫻ 12.9 cm. Usually the flap was harvested on at
least three perforators, mainly arising from the
fifth space.
Mean harvesting time for a single flap was 40
minutes, and all of the procedures were performed bilaterally with a double team to reduce
operative time. Mean operative time was 3 hours,
and the use of anterior intercostal artery perfora-
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Plastic and Reconstructive Surgery • October 2012
Fig. 4. (Left) Anterior intercostal artery perforator flap completely islanded and decorticated. (Right) Increased mobility of the flap after sacrifice of the minor caudal perforators.
Fig. 5. (Left) “Key stitches” to the pectoralis major fascia. (Right) An “autoprosthesis” is shaped and stabilized to the pectoralis major fascia to prevent shearing forces on the perforators.
tor flaps did not add a significant amount of extra
time to the classic mastopexy procedure. All donor
sites were closed primarily. Patients were all discharged on the first postoperative day. Physical
examination was performed 1, 3, 6, and 12 months
after surgery. Within the first month, one patient
needed vertical scar revision of a single breast
and another presented inframammary fold caudal
dislocation that had to be corrected with resuspension under local anesthesia. No other complications were registered. In all follow-up examinations, breasts were soft at palpation, with no
clinical signs of flap necrosis. At 12-month postoperative follow-up, a stable result with good nipple position, breast shape, and projection was registered (Figs. 6 through 8). [See Figure,
Supplemental Digital Content 4, which shows pa-
920
tient 7, http://links.lww.com/PRS/A542. (Left) Intraoperative view: the “autologous implant” has
been shaped and sutured. (Center) Preoperative
view. (Right) Photograph obtained 6 months postoperatively.] Upper abdominal skin laxity was always improved.
DISCUSSION
The use of the intercostal vascular pedicle to
supply a skin flap was first described by Esser in
1931.9 Since then, several anatomical studies have
investigated the anatomy of these vessels.5,6 The
anterior intercostal arteries originate from the internal mammary artery from the first to the sixth
intercostal spaces and from its terminal branch,
the musculophrenic artery, from the seventh to
the ninth spaces. These arteries communicate
Volume 130, Number 4 • Remodeling after Bariatric Mastopexy
Table 1. Patients Who Underwent Anterior Intercostal Artery Perforator Flap Autologous Augmentation
Combined with Inverted-T Mastopexy
Patient
Age
(yr)
Bariatric Procedure
Suprasternal
Notch–to–Nipple
Distance (cm)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
55
50
43
33
28
42
32
51
37
48
35
40
46
34
31
Biliopancreatic diversion
Gastric bypass
Sleeve gastrectomy
Biliopancreatic diversion
Transoral gastroplasty
Biliopancreatic diversion
Sleeve gastrectomy
Sleeve gastrectomy
Biliopancreatic diversion
Biliopancreatic diversion
Sleeve gastrectomy
Biliopancreatic diversion
Biliopancreatic diversion
Biliopancreatic diversion
Biliopancreatic diversion
34.5
Left, 30; right, 28.5
Left, 26; right, 27
Left, 28; right, 27.5
31
Left, 27; right, 27.5
28
Left, 26.5; right, 27.5
29
Left, 30.5; right, 30
30
Left, 30; right, 31.5
Left, 32; right, 31
28.5
Left, 27; right, 25.5
with the posterior intercostal arteries at approximately the medial third of the ribs, constituting a
vascular arcade from which multiple perforators
arise.7 The course of intercostal vessels can be
divided horizontally into four segments: vertebral,
intercostal, intermuscular, and rectal.4 Flaps are
named by the segment from which their vascular
supply arises. The pedicle of the dorsal intercostal
artery perforator flap derives from the vertebral
segment. The dorsal intercostal artery perforator
flap has been used mainly as a pedicled flap for the
closure of midline back defects.10 –12 The lateral
intercostal perforator flap is based on vessels deriving from the costal segment. It was first described by Badran et al. in 198413 and has been
used for correction of facial contour14 and for
breast reconstruction.15–18 The use of this flap for
autologous breast augmentation was first reported
by Hurwitz and Agha-Mohammadi, who performed a “spiral flap.”19 Kwei et al.20 described its
anatomical basis and, in addition to Hamdi and
colleagues,21 reported their experience with the
lateral intercostal artery perforator flap. In 2011,
Akyurek published an article about the use of a
pectoralis muscle sling to prevent the descent of
the flap when used for autologous breast augmentation in bariatric patients.22 The lateral intercostal artery perforator flap has the advantages of
improving breast fullness and correcting the axillary roll at the same time, but a long scar in the
lateral chest wall results from the surgical procedure. Moreover, this flap has limited mobility because of its small arc of rotation and is nourished
by few perforator vessels. In contrast, in the anterior chest, several perforating branches can be
found from the fifth to eighth intercostal seg-
Upper Abdominal
Laxity
Flap
Dimension (cm)
No. of Perforators
Supplying the Flap
⫹⫹
10 ⫻ 18
8⫻7
10 ⫻ 15
10 ⫻ 16
9 ⫻ 18
6 ⫻ 10
8⫻8
8 ⫻ 15
9 ⫻ 16
8 ⫻ 15
10 ⫻ 8
10 ⫻ 9
10 ⫻ 14
8 ⫻ 10
10 ⫻ 15
4
3
5
4
4
3
3
4
4
4
3
3
5
3
4
⫹⫹
⫹
⫹
⫹⫹
⫹
⫹⫹
⫹
ments; these vessels extend horizontally along the
rib cage and anastomose vertically with each other.
Moreover, the vascular system deriving from these
arteries shows anastomoses with the system belonging to the superior epigastric artery.5 The anterior
intercostal artery perforator flap is supplied by
vessels originating from the muscular or rectal
segment of intercostal arteries7 and presents several advantages compared with the lateral intercostal artery perforator flap, such as the larger
amount of harvestable tissue because of the
greater number of perforators and superior mobility. The use of the anterior intercostal artery
perforator flap has been described for coverage
of epigastric abdominal wounds,23 for hand
reconstruction,5 for correction of sequelae from
augmentation mammaplasty24 and for reconstruction of sternal defects.7 Anterior intercostal perforators are also the vessels that nourish the inferior dermolipoglandular flap used in mastopexy
procedures and first presented by Dr. Ribeiro at
the Congress of the Brazilian Society of Plastic
Surgery in 1971. This flap is vascularized by arteries that arise from the fourth to sixth intercostal
spaces. In Dr. Ribeiro’s technique,25,26 it is harvested from the lower pole of the breast, then
advanced cranially as a pedicled flap and sutured
to the pectoralis major fascia to provide breast
firmness and projection. Modifications of the classic Ribeiro technique to address massive weight
loss patients have already been described in the
literature. Daniel suggested the passage of the flap
under a loop of pectoral muscle to improve longterm projection,27 whereas Ritz et al. reported
their experience in passing the flap only under the
pectoralis fascia.28 However, these procedures im-
921
Plastic and Reconstructive Surgery • October 2012
Fig. 6. Photographs of patient 3 obtained (left) preoperatively and (right) 6 months postoperatively. Notice the improvement in abdominal skin laxity, with transition from convexity to concavity (lateral view).
ply increased morbidity and could harm oncologic
diagnosis and treatment. Perforator flaps in the
past decade have enhanced tissue recruitment and
flap mobility, and in this sense, our anterior intercostal artery perforator flap can be considered
an evolution of Ribeiro’s flap without many
tradeoffs. Vessel dissection in fact provides superior mobility compared with the classic Ribeiro
flap, without the need to perform skeletonization
through the muscle. Even if the anterior intercostal artery perforator flap may be nourished by the
fifth to eighth intercostal space perforators, our
experience proved that safely harvesting a large
922
amount of tissue by islanding the flap on only
two or three perforators arising from the fifth or
sixth intercostal space is possible. However, the
fifth intercostal space perforators should be preferred, as the more caudal ones are more difficult to spare when the flap is advanced cranially
and the inframammary fold redefined. In this
case, distal flap vascularization is maintained by
the vertical network of linking vessels connecting
adjacent intercostal spaces.5 Furthermore, minor
lateral branches may be cut either to increase the
flap’s mobility or to improve its reshaping in a sort
of round autologous implant. Finally, the advan-
Volume 130, Number 4 • Remodeling after Bariatric Mastopexy
Fig. 7. Photographs of patient 1 obtained (left) preoperatively and (right) 12 months postoperatively.
Fig. 8. Lateral preoperative (right) and postoperative (left) views of patient 1.
tage of correcting at the same time upper abdominal lipodystrophy and ptosis must also be emphasized. Currently, upper abdominal tissue laxity
may be addressed with several surgical strategies,
such as anchor-line, reverse, or circumferential
abdominoplasties.29,30 In our technique, the harvesting of abdominal tissue has two main advantages: first, it adds further projection to the reconstructed breast; and second, it induces an
abdominal tissue lift, solving superior abdominal
ptosis, which is often refractory to standard ab-
dominoplasty. The viability of the flap has never
been compromised because of many perforators
nourishing this flap, and no major complications
have been recorded. In some cases, a temporary
distortion of the inframammary fold profile may
be experienced, especially in cases of large tissue
recruitment from the abdomen.
We never performed abdominoplasty and
mastopexy with anterior intercostal artery perforator flap surgery at the same time because of the
increased risk of complications and the additional
923
Plastic and Reconstructive Surgery • October 2012
tension that would be placed on the inframammary fold. In planning the two procedures, we
would perform abdominoplasty first and then, after 6 months, when the result was stable and the
tension had been redistributed, breast reshaping.
In our experience, the anterior intercostal artery
perforator flap proved to be a safe and reliable
option in bariatric mastopexy: it requires easy dissection and allows the harvesting of a large
amount of tissue with a wide arc of rotation, thus
overcoming the need for implant placement. Possible contraindications to this technique are large
scars in the area of flap harvesting, such as from
open cholecystectomy, or prior inferior pedicle
breast reduction.
CONCLUSIONS
Autologous augmentation with the anterior
intercostal artery perforator flap represents a valid
option for breast reshaping in the massive weight
loss population. The procedure can be easily standardized and is easy to perform, increases breast
volume and projection, and corrects upper abdominal skin laxity usually not responsive to classic abdominoplasty procedures. Inverted-T mastopexy
with the anterior intercostal artery perforator flap
proved to be a very good technique for restoring
breast shape and projection in postbariatric patients.
Stefania Tenna, M.D., Ph.D.
Plastic and Reconstructive Surgery Unit
Campus Bio-Medico di Roma University
Via Alvaro del Portillo
200-00128 Rome, Italy
[email protected]
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
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