Analyzing the Vascular Architecture of the Free TRAM Flap Using Intraoperative Ex Vivo Angiography

Ohjimi, Hiroyuki; Era, Kozo; Fujita, Tadayoshi; Tanaka, Tetsuichiro; Yabuuchi, Rie

doi:10.1097/01.prs.0000169717.84221.d7

Cited by 40 publications

(23 citation statements)

References 33 publications

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“…The BF PET was lower in zone I than in zones II and III, which somewhat contrasts with previous results. 13,37,38 The explanation for this controversy could be different monitoring methods used in these previous publications measuring cutaneous perfusion and not BF PET . 13,33 Furthermore, the greater heterogeneity in zones I and II in comparison to zone III supports the assumption that monitoring blood flow from the more superficial parts of the flap might not present the perfusion of the whole flap.…”

Section: Discussionmentioning

confidence: 86%

Perfusion in free breast reconstruction flap zones assessed with positron emission tomography

et al. 2010

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The aim of this pilot study was to determine the postoperative blood perfusion (BF(PET)) and perfusion heterogeneity (BF(PET) HG) in free microvascular breast reconstruction flap zones with positron emission tomography (PET). Regional BF(PET) and BF(PET) HG of the adipose tissue in medial, central, and lateral parts of 13 free flaps were assessed on the first postoperative morning with PET using oxygen-15-labeled water ([(15)O]H(2)O) in 12 patients undergoing breast reconstruction with a deep inferior epigastric perforator (DIEP) or a transverse rectus abdominis muscle (TRAM) flap. The mean BF(PET) values did not differ between DIEP and TRAM flaps (P = 0.791). The mean BF(PET) values were higher in zone III compared with zone I (P = 0.024). During follow-up, fat necrosis was identified in three patients in the medial part (zone II) of the flap. However, the adipose tissue BF(PET) assessed on the first postoperative day from all zones of the flap using PET with radiowater was normal. The BF(PET) HG was higher in the control side (i.e., in the healthy breast tissue) compared with the flap (P = 0.042). The BF(PET) HG was lower in zone III than in zone I (P = 0.03) and in zone II (P < 0.001). In this pilot study, PET was used for the first time for studying the adipose tissue perfusion in different zones in free flaps in a clinical setup, finding that the mean BF(PET) values did not differ between DIEP and TRAM flaps, and that zone II was sometimes not as well perfused as zone III supporting revisited zone division.

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Section: Discussionmentioning

confidence: 86%

Perfusion in free breast reconstruction flap zones assessed with positron emission tomography

et al. 2010

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“…Although few in number, subsequent studies have varied in their accounts of this branching pattern. Three separate studies, with two of these from the same research group, describe a uniformly bifurcating pattern of the DIEA (Ohjimi et al, 2002(Ohjimi et al, , 2005Tansatit et al, 2006). Of these, two studies used intraoperative ex-vivo angiography for analysis and the other was a dissection study in embalmed cadavers.…”

Section: Named Source Vesselsmentioning

confidence: 94%

“…Moreover, they found that all periumbilical and infraumbilical perforators are derived solely from the DIEA. Further anatomical studies have added to the literature, utilizing a combination of dissection, radiography, and angiography to describe the location of these perforators (Itoh and Arai, 1993;Konerding et al, 1997;Stokes et al, 1998;Heitmann et al, 2000;El-Mrakby and Milner, 2002;Ohjimi et al, 2002Ohjimi et al, , 2005Tansatit et al, 2006).…”

Section: The Musculocutaneous Perforators Of the Dieamentioning

confidence: 96%

“…Explanations for the differences in perfusion between Zones II and III have been proposed to justify the contemporary classification of zone perfusion. Anatomical studies have demonstrated fewer vascular communications across the midline than between the ipsilateral zones (Blondeel et al, 2000;Ohjimi et al, 2005). Furthermore, perforators within Zone I have a greater tendency to be orientated toward the ipsilateral adjacent zone, providing an increased flow to the newly classified Zone II (Tregaskiss, 2006).…”

Section: Perfusion Zones (Angiosomes) Of the Anterior Abdominal Wallmentioning

confidence: 97%

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Reviewing the vascular supply of the anterior abdominal wall: Redefining anatomy for increasingly refined surgery

2008

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The abdominal wall integument is becoming the standard donor tissue for postmastectomy breast reconstruction, with its vascular supply of key importance to the reconstructive surgeon. Refinements in tissue transfer, from pedicled to free flaps and musculocutaneous to perforator flaps, have required increasing understanding of finer levels of this vascular anatomy. The widespread utilization of the deep inferior epigastric artery (DIEA) perforator flap, particularly for breast reconstruction, has rekindled clinical interest in further levels of anatomical detail, in particular the location and course of the musculocutaneous perforators of the DIEA. Advances in operative techniques, and anatomical and imaging technologies, have facilitated an increase in this understanding. The current review comprises an appraisal of both the anatomical and clinical literature, with a view to highlighting the key anatomical features of the abdominal wall vasculature as related to reconstructive flaps.

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“…In highly obese subjects, fat necrosis extended even to the craniad side of zone II. Ohjimi et al 11,12 reported that blood circulation is poorer in the craniad than in the caudal side of zone II, suggesting that this region has a higher risk of fat necrosis in obese patients. In our series of MS-2 free TRAM flaps, 7 of 8 patients (87.5%) who had partial fat necrosis were obese with BMI of 25 or above.…”

Section: Discussionmentioning

confidence: 97%

Muscle sparing‐2 transverse rectus abdominis musculocutaneous flap for breast reconstruction: A comparison with deep inferior epigastric perforator flap

et al. 2008

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Breast reconstruction using free transverse rectus abdominis musculocutaneous (TRAM) flap can be divided into 4 muscle-sparing (MS) types: conventional TRAM flap containing full width muscle as MS-0, while deep inferior epigastric perforator (DIEP) flap containing absolutely no muscle as MS-3. We include only the muscle portion between the medial row and lateral row perforator vessels in TRAM flap, which is designated as MS-2. Between October 1999 and April 2006, the same surgeon performed 82 breast constructions using MS-2 free TRAM flaps in 79 patients. All the flaps survived. Postoperative complications included partial fat necrosis in 8 cases, all corresponding to zone IV or zone II. Bulging of donor site occurred in 5 patients, 4 of whom were obese and 1 had bilateral flap harvest. Compared with our own reconstructions using DIEP flap (30 cases), there were no significant differences in operative time and blood loss between the two techniques. In conclusion, MS-2 free TRAM flap is a useful technique for breast construction considering the easy surgical techniques, length of the vascular pedicle that can be harvested, and the degree of freedom of the flap.

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Analyzing the Vascular Architecture of the Free TRAM Flap Using Intraoperative Ex Vivo Angiography

Cited by 40 publications

References 33 publications

Perfusion in free breast reconstruction flap zones assessed with positron emission tomography

Perfusion in free breast reconstruction flap zones assessed with positron emission tomography

Reviewing the vascular supply of the anterior abdominal wall: Redefining anatomy for increasingly refined surgery

Muscle sparing‐2 transverse rectus abdominis musculocutaneous flap for breast reconstruction: A comparison with deep inferior epigastric perforator flap

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