Abdominal perforator exchange flap (APEX): A classification of pedicle rearrangements

Abstract

Introduction Abdominal‐based reconstruction is the most commonly performed method for breast reconstruction after mastectomy using the patient's own tissues. DIEP flap has allowed to reduce the donor site morbidity but the incidence of bulging or hernia remains still high, especially when flap is based on multiple perforators. Abdominal Perforator Exchange flap (APEX) represents a further step forward in preserving the abdominal wall structures by disassembling the pedicle components and their reconstitution at the end of the dissection. In this study, we explore the possible anatomical configurations of perforators exchange for APEX, providing a simple classification of perforators reconstitution patterns and the possible clinical implications. Materials and methods A retrospective study was conducted on patients who received APEX flap for abdominal based breast reconstruction. Preoperative CT scans and procedure descriptions were analyzed to identify the vascular patterns during flap harvesting and the pedicle reconstitution sites. The onset of abdominal wall and flap related complications were investigated. Results APEX flap was performed on 51 women and four vascular patterns were identified. We identified the Type A pattern in 36 cases (70.6%), the Type B pattern in 8 (15.7%), and the Type C pattern in 5 (9.8%). We performed an extra‐anatomical reanastomosis (Type D) in only two case (3.9%) (p = .09). We recorded anastomotic problems in five pedicles' reconstitution and the odds ratio showed a possible correlation between the localization of pedicle division and the anastomosis problems (p > .05). No total or partial flap loss was recorded during this study. Marginal fat necrosis was clinically observed in three cases, which had very large flaps. No bulging or hernia was recorded. Conclusion Our perforators exchange classification for abdominal‐based flap helps clinician in planning the surgery and also in describing the procedure easily allowing a more efficient communication. This classification could be used to approach perforator flaps with multiple vessels at other anatomical locations as well.

A New Era in Perforator Flap Surgery for Breast Reconstruction: A Comparative Study of Robotic versus Standard Harvest of Bilateral Deep Inferior Epigastric Artery Perforator Flaps

“…Operative details were abstracted including timing of reconstruction (delayed vs. immediate), mastectomy specimen weight and extramicrovascular anastomosis including additional venous anastomosis (>1), the use of vein grafts, and abdominal perforator exchange (APEX) anastomosis. [21][22][23] Simultaneous procedures such as neurotization, lymph node transfer, or other reconstructive procedures were recorded. 24 Surgical outcomes included the number of perforators, fascial incision, and pedicle lengths, use of surgical mesh at the abdominal donor site, and total operative time.…”

“…In instances where two closely related perforators were unavailable, we adopted the APEX technique, originally developed for open DIEP flap harvest but highly valuable in rDIEP. 22,23 We performed the dissection of the second perforator through a minimal fascial incision, dividing the perforator when sufficient length was achieved. Anastomosis to the superior pedicle extension or large side branch is performed ex vivo.…”

Building Complex Autologous Breast Reconstruction Program: A Preliminary Experience

“…In the APEX flap, deep inferior epigastric vessels are harvested, but the abdominal wall structures are preserved by temporarily dividing the perforator or pedicle and reconstructing them at the end of dissection. Once outside the patient, the ligated vessels are microanastomosed [18]. This technique is recommended when more than one-third of the muscle belly or thickness could be lost, or two or more motor branches would be divided during isolation, especially in cases of lateral row perforators [18].…”

“…Once outside the patient, the ligated vessels are microanastomosed [18]. This technique is recommended when more than one-third of the muscle belly or thickness could be lost, or two or more motor branches would be divided during isolation, especially in cases of lateral row perforators [18]. While this technique preserves the rectus abdominis muscle, it is very technically challenging and time-intensive to perform additional microanastomosis.…”