Objective:To investigate the clinical effects of combined tissue flap transplantation in repairing giant chest wall defects.Methods:This study was a retrospective observational study. From August 2013 to December 2020, 31 patients with chest wall tumor or radiation ulcer after radical resection of chest wall tumor and conformed to the inclusion criteria were admitted to the Department of Breast Oncoplastic Surgery of Hunan Cancer Hospital, including 12 males and 19 females, aged 25-71 years. After resection of tumor or ulcer and wound debridement, the area of secondary chest wall defect was 300-600 cm 2 with length of 16-35 cm and width of 16-32 cm. According to the actual situation of the patients and the preoperative design, the chest wall defects were repaired with the flexible combination of perforator flaps and myocutaneous flaps from different donor sites, and the area of the combined tissue flap was 260-540 cm 2 with length of 20-30 cm and width of 13-20 cm. Free posteromedial thigh perforator flap+free anterolateral thigh myocutaneous flap were used in 2 patients, free deep inferior epigastric artery perforator flap+free anterolateral thigh myocutaneous flap were used in 5 patients, free deep inferior epigastric artery perforator flap+pedicled rectus abdominis myocutaneous flap+free anterolateral thigh myocutaneous flap were used in 7 patients, free deep inferior epigastric artery perforator flap+pedicled rectus abdominis myocutaneous flap+pedicled latissimus dorsi myocutaneous flap were used in 2 patients, and bilateral free anterolateral thigh myocutaneous flaps were used in 15 patients. For the remaining small area of superficial tissue defect after being repaired by combined tissue flaps, skin graft was used to repair or delayed local flap transfering was performed after the tissue flaps survived and edema subsided. The appropriate blood vessels in the donor and recipient sites were selected for anastomosis to reconstruct the blood supply of tissue flaps. The wounds in the donor sites of tissue flaps that can be directly sutured were sutured directly; for those that cannot be sutured directly, the skin grafting or delayed suture was performed. The anastomosis of blood vessels in the recipient sites, operation length, and postoperative hospital stay were recorded. The survivals of tissue flaps and skin grafts, the shape and texture of reconstructed chest wall, the wound healing, scar formation, and function of donor sites of tissue flaps, and the scar formation of the donor sites of skin grafts were observed after operation. Tumor recurrence and death of recurrent patients were followed up after operation. Results:The blood vessels in the recipient sites were anastomosed as follows: proximal internal thoracic vessels for 24 times, distal internal thoracic vessels for 12 times, trunk of thoracodorsal vessels for 4 times, anterior serratus branches of thoracodorsal vessels for 8 times, and thoracoacromial vessels for 12 times. The operation length was 6.0 to 8.5 hours, and the postoperative hospital stay was 9 to 21 days. Necrosis at the edge of partial tissue flaps occurred in 4 patients after operation, which healed after dressing change, and the tissue flaps and skin grafts of the other patients survived completely. The shape and texture of the reconstructed chest wall were good. Four patients had poor wound healing in the donor sites of abdominal tissue flaps, which healed after dressing change and local drainage. Only linear scar was left in the donor sites of all tissue flaps, and there was no obvious dysfunction in the donor sites of tissue flaps. Mild hypertrophic scar was left in the donor sites of skin grafts. During follow-up of 9 to 36 months after operation, 6 patients had tumor recurrence, and the recurrence time was 5 to 20 months after operation. After comprehensive treatment for patients with tumor recurrence, 3 patients died.Conclusions:Transplantation of combined tissue flaps in repairing the giant chest wall defects can shorten the time of total operation and hospital stay, and avoid multiple operations. After operation, patients had good chest wall appearance, with reduced tumor recurrence in patients with chest wall tumor.

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.

In December 2021, a 37-year-old female patient was admitted to the Department of Oncology Plastic Surgery, Hunan Cancer Hospital, 32 months after bilateral mastectomy. After admission, it was planned to perform bilateral breast reconstruction with bilateral free deep inferior epigastric artery perforator (DIEP) flap and bilateral free posterior medial thigh perforator flap. The ipsilateral lower abdominal flap and posterior medial thigh flap were stacked to reconstruct the ipsilateral breast, and the vascular pedicle of profunda artery perforator was anastomosed with the distal end of internal mammary vessel, the deep inferior epigastric artery was anastomosed with the proximal end of the internal mammary vessel. During the operation, the blood supply of the flap was good, and the donor sites of the thigh and abdomen were closed directly. The postoperative course of the patient was stable, the flap survived well, and the donor site healed well. After 1 month follow-up, the appearance and function of the donor area of abdomen and thigh were good, no obvious complications were found, and the reconstructed breast shape was satisfactory. This case suggests that the combined transplantation of free DIEP flap and posterior medial thigh perforator flap is suitable for the reconstruction of large breast.

On June 15, 2021, a female patient with right breast cancer aged 43 years old was admitted in Hunan Cancer Hospital. She received left mastectomy 13 years ago and left breast reconstruction with pedicled rectus abdominis myuocutaneous flap 6 years ago. After admission, she received right mastectomy and immediate right breast reconstruction with bilateral free medial arm perforator flaps. The lateral side of the breast was reconstructed with the ipsilateral medial arm flap. The superior ulnar collateral vessels were anastomosed with the proximal end of the lateral thoracic artery and distal end of the lateral thoracic vein. And the contralateral medial arm flap was used to reconstruct the medial part of the breast. The superior ulnar collateral vessels were anastomosed with the proximal and distal ends of the internal mammary vessels. After revascularization, the blood supply of the flap was good, and the donor sites were closed directly. The postoperative course of the patient was stable, the flap survived well, and the donor area healed well. In the two-month follow-up, the appearance and function of the flap donor area was good, there were no obvious complications, while the reconstructed breast shape was not satisfactory. This case suggests that the combined transplantation of bilateral free arm medial perforator flaps is suitable for small and medium-sized breast reconstruction, but not enough for large-volume breast reconstruction.

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.

In December 2021, a 37-year-old female patient was admitted to the Department of Oncology Plastic Surgery, Hunan Cancer Hospital, 32 months after bilateral mastectomy. After admission, it was planned to perform bilateral breast reconstruction with bilateral free deep inferior epigastric artery perforator (DIEP) flap and bilateral free posterior medial thigh perforator flap. The ipsilateral lower abdominal flap and posterior medial thigh flap were stacked to reconstruct the ipsilateral breast, and the vascular pedicle of profunda artery perforator was anastomosed with the distal end of internal mammary vessel, the deep inferior epigastric artery was anastomosed with the proximal end of the internal mammary vessel. During the operation, the blood supply of the flap was good, and the donor sites of the thigh and abdomen were closed directly. The postoperative course of the patient was stable, the flap survived well, and the donor site healed well. After 1 month follow-up, the appearance and function of the donor area of abdomen and thigh were good, no obvious complications were found, and the reconstructed breast shape was satisfactory. This case suggests that the combined transplantation of free DIEP flap and posterior medial thigh perforator flap is suitable for the reconstruction of large breast.

On June 15, 2021, a female patient with right breast cancer aged 43 years old was admitted in Hunan Cancer Hospital. She received left mastectomy 13 years ago and left breast reconstruction with pedicled rectus abdominis myuocutaneous flap 6 years ago. After admission, she received right mastectomy and immediate right breast reconstruction with bilateral free medial arm perforator flaps. The lateral side of the breast was reconstructed with the ipsilateral medial arm flap. The superior ulnar collateral vessels were anastomosed with the proximal end of the lateral thoracic artery and distal end of the lateral thoracic vein. And the contralateral medial arm flap was used to reconstruct the medial part of the breast. The superior ulnar collateral vessels were anastomosed with the proximal and distal ends of the internal mammary vessels. After revascularization, the blood supply of the flap was good, and the donor sites were closed directly. The postoperative course of the patient was stable, the flap survived well, and the donor area healed well. In the two-month follow-up, the appearance and function of the flap donor area was good, there were no obvious complications, while the reconstructed breast shape was not satisfactory. This case suggests that the combined transplantation of bilateral free arm medial perforator flaps is suitable for small and medium-sized breast reconstruction, but not enough for large-volume breast reconstruction.

Objective:To investigate the anatomical basis and the clinical effect of superficial circumflex iliac artery perforator (SCIP) flap in repairing defects after radical resection of oral squamous cell carcinoma.Methods:Bilateral superficial circumflex iliac artery and vein were dissected in ten fresh cadavers. From June 2017 to June 2019, the patients with oral squamous carcinoma received resection and reconstructed with SCIP flap immediately. Before the operation, the locations of SCIP were detected and marked by Doppler. According to the size of the defect in the oral cavity, SCIP flaps were designed and raised, then transferred to the defect area of the oral cavity. The arteries and veins were anastomosed under a microscope. The survival and functional recovery of the flap were evaluated after the operation. Patients were followed up for 6-30 months.Results:The bilateral dissection of fresh cadavers yielded anatomical data of 20 superficial circumflex iliac arteries and veins. The diameter of the circumflex iliac artery was (1.94±0.30) mm, with a superficial branch [mean diameter, (0.94 ± 0.25) mm)] and a deep branch[mean diameter, (1.25 ± 0.27) mm)]. At least two (2.15 ± 0.37) myocutaneous perforators arose from the deep branch that passed through the sartorius muscle. The diameter of the myocutaneous perforator was (0.75±0.15) mm. The diameter of the circumflex iliac vein was (1.72±0.14) mm. The pedicle length of the superficial branch was (6.5±1.2) cm, the pedicle length of the deep branch was (8.5±1.9) cm, and the pedicle length of the vein was (9.2±2.1) cm. Sixteen patients with 14 males with oral squamous carcinoma were included, aged from 31 to 70 years (average, 48.8 years). The flap size ranged from 6 cm×4 cm to 12 cm×6 cm. The mean pedicle length of the artery was 6.8 cm, and the mean pedicle length of the vein was 7.6 cm. One flap suffered from venous congestion postoperatively and was lost ultimately. The other flaps all survived. Two patients were noted with donor site lymphatic fistula, and the drainage tube removal was delayed. Patients were followed up for 6-30 months. One patient was noted with cervical metastasis nine months after the operation. No recurrence or metastasis was found in other patients during the follow-up period. No donor-site-related complication occurred, and all patients were satisfied with the recovery of the oral function.Conclusions:The SCIP flap is a good choice for the reconstruction of oral cavity defects following resection for oral squamous cell carcinoma with the proper thickness, soft texture, constant diameter and length of vascular pedicle, stable blood supply, and concealed donor site.

Objective:To study vascular anastomosis patterns of internal mammary vessels (IMAV) as recipient vessels in deep inferior epigastric artery perforator (DIEP) flap breast reconstruction and evaluate clinical outcomes.Methods:Early stage breast cancer patients receiving modified radical surgery with either immediate DIEP flap breast reconstruction or delayed DIEP breast reconstruction in the Department of Oncoplastic Plastic Surgery , Hunan Cancer Hospital from September, 2015 to January, 2019 were retrospectively analyzed. Unilateral pedicled DIEP flap was used in all cases with Zone Ⅳ discarded. IMAV were chosen as sole recipient vessels. According to the anatomy of flap pedicle and IMAV, the corresponding anastomosis patterns were selected, including: (1) two ends method. (2) one proximal end method. (3) two proximal ends method. (4) proximal trunk and its branch method. (5) distal end method. (6) proximal end to side method. Flap survival, breast morphology, recurrence of breast cancer, donor site wound healing were followed up. Descriptive methods were used for statistical analysis.Results:Two hundred and eight breast cancer patients were enrolled. The average age was 38.7±3.5 years (27-65 years). One hundred and nine cases received immediate breast reconstruction and 99 received delayed breast reconstruction. The average weight of flap was 410 g (295 - 640 g). The flap length was 23.9±0.8 cm. The width was 12.2±0.5 cm. The thickness of flap was 4.3±0.4 cm. The length of pedicle was 10.9±0.3 cm.One hundred and ninty-four DIEP flaps had two accompanying veins and 14 had one accompanying vein. One hundred and seventy-three cases had one internal mammary vein and 35 had two internal mammary veins. Vascular anastomosis patterns: Method 1 was used in 89 cases, method 2 in 49 cases, method 3 in 35 cases, method 4 in 25 cases, method 5 in 7 cases and method 6 in 3 cases. Among 208 flaps two failed. One flap using method 1 had vascular pedicle torsion and the other using method 2 had venous thrombosis. One case received secondary implant reconstruction following debridement and the other had recipient site was closed primarily. All the other 206 flaps survived completely without contracture deformation. The reconstructed breasts had good shape and elasticity. Linear scar was left on the donor sites. The abdominal wall function was not affected. All patients were followed up for 12-48 months (22.6 months on average) with satisfactory results. One case had brain metastasis and received further treatment. No local recurrence was found.Conclusions:According to the specific anatomy of the vascular pedicle of DIEP flap and the internal mammary vessels, the vascular anastomosis method was selected flexibly to ensure breast reconstruction safety with satisfactory results.

Objective:To investigate the anatomical basis and the clinical effect of superficial circumflex iliac artery perforator (SCIP) flap in repairing defects after radical resection of oral squamous cell carcinoma.Methods:Bilateral superficial circumflex iliac artery and vein were dissected in ten fresh cadavers. From June 2017 to June 2019, the patients with oral squamous carcinoma received resection and reconstructed with SCIP flap immediately. Before the operation, the locations of SCIP were detected and marked by Doppler. According to the size of the defect in the oral cavity, SCIP flaps were designed and raised, then transferred to the defect area of the oral cavity. The arteries and veins were anastomosed under a microscope. The survival and functional recovery of the flap were evaluated after the operation. Patients were followed up for 6-30 months.Results:The bilateral dissection of fresh cadavers yielded anatomical data of 20 superficial circumflex iliac arteries and veins. The diameter of the circumflex iliac artery was (1.94±0.30) mm, with a superficial branch [mean diameter, (0.94 ± 0.25) mm)] and a deep branch[mean diameter, (1.25 ± 0.27) mm)]. At least two (2.15 ± 0.37) myocutaneous perforators arose from the deep branch that passed through the sartorius muscle. The diameter of the myocutaneous perforator was (0.75±0.15) mm. The diameter of the circumflex iliac vein was (1.72±0.14) mm. The pedicle length of the superficial branch was (6.5±1.2) cm, the pedicle length of the deep branch was (8.5±1.9) cm, and the pedicle length of the vein was (9.2±2.1) cm. Sixteen patients with 14 males with oral squamous carcinoma were included, aged from 31 to 70 years (average, 48.8 years). The flap size ranged from 6 cm×4 cm to 12 cm×6 cm. The mean pedicle length of the artery was 6.8 cm, and the mean pedicle length of the vein was 7.6 cm. One flap suffered from venous congestion postoperatively and was lost ultimately. The other flaps all survived. Two patients were noted with donor site lymphatic fistula, and the drainage tube removal was delayed. Patients were followed up for 6-30 months. One patient was noted with cervical metastasis nine months after the operation. No recurrence or metastasis was found in other patients during the follow-up period. No donor-site-related complication occurred, and all patients were satisfied with the recovery of the oral function.Conclusions:The SCIP flap is a good choice for the reconstruction of oral cavity defects following resection for oral squamous cell carcinoma with the proper thickness, soft texture, constant diameter and length of vascular pedicle, stable blood supply, and concealed donor site.