Application of classification of the accompanying vein of deep inferior epigastric artery and vascular anastomosis strategy in breast reconstruction
10.3760/cma.j.cn114453-20220508-00141
- VernacularTitle:腹壁下动脉伴行静脉分型及吻合策略在乳房再造中的应用
- Author:
Dajiang SONG
1
;
Zan LI
;
Yixin ZHANG
;
Bo ZHOU
;
Chunliu LYU
;
Yuanyuan TANG
;
Liang YI
;
Zhenhua LUO
Author Information
1. 湖南省肿瘤医院肿瘤整形外科，长沙 410008
- Keywords:
Mastectomy;
Breast reconstruction;
Lower abdominal flap;
Vascular anastomosis;
Deep inferior epigastric artery;
Free flap
- From:
Chinese Journal of Plastic Surgery
2023;39(4):351-358
- CountryChina
- Language:Chinese
-
Abstract:
Objective:To explore the application of the classification of the accompanying vein of deep inferior epigastric artery and vascular anastomotic strategy in breast reconstruction.Methods:The data of patients who underwent breast reconstruction after breast cancer surgery with unilateral free lower abdominal flap transplantation in Hunan Cancer Hospital from October 2015 to January 2021 were retrospectively analyzed. During surgery, free deep inferior epigastric artery perforator (DIEP) flap or free muscle-sparing rectus abdominis musculocutaneous flap was used for breast reconstruction, and the recipient vessel was internal mammary vessel. The anatomy of the accompanying vein of the deep inferior epigastric artery can be divided into three types: independent type, including one branch type and two branch type; Y-shaped structure; H-shaped structure. Direct anastomosis was used for independent veins. There were five methods of vascular anastomoses for Y-shaped and H-shaped accompanying vein: (1) direct anastomosis; (2) the Y-shaped common stem segment was removed and the two accompanying veins were anastomosed respectively; (3) ligate the communicating branch and anastomose the two accompanying veins respectively; (4) the communicating branch was reserved and the two accompanying veins were anastomosed respectively; (5) ligate the smaller accompanying vein and anastomose the larger accompanying vein. Methods 1 and 2 were suitable for Y-shaped accompanying veins, and methods 3 to 5 were suitable for H-shaped accompanying veins. The excessively long inferior abdominal artery segment was removed during the operation. The complications of intraoperative vascular anastomosis were counted, and the survival of flap, aesthetics of breast reconstruction and tumor recurrence were followed up.Results:A total of 173 female patients were included, ranging from 26 to 60 years, with an average age of 41.2 years. There were 92 cases of immediate breast reconstruction and 81 cases of delayed breast reconstruction. 109 cases of free DIEP flap and 64 cases of free muscle-sparing rectus abdominis musculocutaneous flap were harvested. The length of the flap was (26.9±1.9) cm, the width of the flap was (11.3±0.7) cm, the length of the vascular pedicle was (10.5±0.4) cm. The anatomical type of the deep inferior epigastric artery with only one accompanying vein accounted for 16 cases, and the veins were anastomosed directly. The anatomical type of Y-shaped accompanying vein accounted for 14 cases, of which 5 cases were anastomosed directly using method 1, 3 cases were anastomosed directly using method 1 after partial resection of the third costal cartilage to create a groove, and 6 cases were anastomosed using method 2. The H-shaped accompanying vein of the deep inferior epigastric artery was found in 143 cases. In 96 cases, vascular anastomosis were accomplished using method 3, 19 cases were anastomosed using method 4 and 28 cases were anastomosed using method 5. In 97 cases, the excessively long segment of the deep inferior epigastric artery were trimmed before vascular anastomosis. The average length of the trimmed segment was (2.7±0.7) mm. There were 6 cases of vascular anastomotic complications during operation, of which 2 patients were treated with method 1. Venous entrapment occurred during operation and was relieved after changing into method 2. The venous anastomosis methods adopted in the other 4 cases included 1 case of method 2, 1 case of method 3, and 2 cases of method 4, all of which were relieved of vessel entrapment by timely adjusting the placement of vessel pedicles. Postoperative flap necrosis occurred in 1 case. The vein anastomosis was direct Y-shaped vein anastomosis. The remaining 172 cases were completely successful. The patients were followed up for 10 to 36 months, with an average of 18.7 months. The reconstructed breast shape was good, the texture was soft, without flap contracture and deformation. Only linear scar remained in the donor site of the flap, which had no significant effect on the function of the abdominal wall. No tumor recurrence was observed.Conclusion:By flexibly adjusting the vascular anastomosis strategy according to the classification of the accompanying vein of the deep inferior epigastric artery, the blood supply of the free lower abdominal flap transfer in breast reconstruction can be guaranteed to the greatest extent.
