From the Plastic and Reconstructive Surgery and Microsurgery Department, Mexican Institute of Social Security; and Artis Plastic Surgery.
Plast Reconstr Surg. 2021 Nov 1;148(5):715e-719e. doi: 10.1097/PRS.0000000000008481.
Abdominal flap-based breast reconstruction is challenging in the overweight and obese population not only because of increased donor-site complications, but also because excessive flap thickness makes inset cumbersome, requiring thinning and remodeling that frequently result in aesthetically poor outcomes.
The authors started by studying 10 deep inferior epigastric artery perforator flaps with angiographic computed tomography. Then, they prospectively performed 21 breast reconstructions using a superficial thinning technique reliant on a constant suprafascial vessel as the pedicle for the remaining deep fat and compared the rate of complications with their previous experience using traditional flap thinning techniques.
All samples studied showed a suprafascial division of the main perforator. Two constant branches were identified, one coursing over the Scarpa fascia and displaying a robust network of linking vessels with the subcutaneous and subdermal plexuses. That anatomical insight was used to develop a flap-thinning technique tested on 21 consecutive high-body mass index patients. A 7-year retrospective analysis (n = 164) showed no significant correlation between body mass index and incidence of complications except for a long-term upper pole step deformity that was associated with increasing body mass index (p = 0.001). No statistically significant difference in complications was found comparing high-body mass index patients from the retrospective group (n = 72) with the superficial thinning group, but a highly suggestive difference (p = 0.061) was found regarding the avoidance of the step deformity using the superficial thinning technique.
The presence of a constant suprafascial perforator branch makes superficial DIEP thinning a safe technique that facilitates inset and improves the reconstructed breast contour of obese patients.
CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.
在超重和肥胖人群中，基于腹部皮瓣的乳房重建不仅由于供区并发症增加而具有挑战性，而且由于皮瓣厚度过大使得植入变得繁琐，需要进行变薄和重塑，这经常导致美学效果不佳。
作者首先通过血管造影计算机断层扫描研究了 10 例深下腹动脉穿支皮瓣。然后，他们前瞻性地使用浅层变薄技术进行了 21 例乳房重建，该技术依赖恒定的皮下血管作为蒂部，用于剩余的深层脂肪，并将并发症发生率与使用传统皮瓣变薄技术的先前经验进行了比较。
所有研究的样本均显示出皮瓣的皮下分离。确定了两个恒定的分支，一个在 Scarpa 筋膜上运行，并显示出与皮下和皮下丛相连的强大网络。这种解剖学见解被用于开发一种皮瓣变薄技术，该技术已在 21 例连续的高身体质量指数患者中进行了测试。7 年的回顾性分析（n = 164）表明，除了与身体质量指数相关的长期上极台阶畸形外（p = 0.001），身体质量指数与并发症发生率之间没有显著相关性。在比较回顾性组（n = 72）和浅层变薄组的高身体质量指数患者的并发症时，没有发现统计学上的显著差异，但在使用浅层变薄技术避免台阶畸形方面发现了高度提示性的差异（p = 0.061）。
恒定的皮下穿支分支的存在使浅层 DIEP 变薄成为一种安全的技术，它便于植入并改善肥胖患者的重建乳房轮廓。
临床问题/证据水平：治疗，IV。
