Nghiên cứu sử dụng vạt da nhánh xuyên động mạch thượng vị dưới sâu trong điều tri di chứng phẫu thuật cắt bỏ ung thư vú tt tiếng anh

MINISTRY OF EDUCATION

MINISTRY OF DEFENCE

MILITARY MEDICAL UNIVERSITY

NGUYEN VAN PHUNG

STUDY TO USE THE DEEP INFERIOR
EPIGASTRIC PERFORATOR FLAP IN
TREATMENT OF SEQUELAE OF BREAST
CANCER SURGERY

Speciality: Surgery
Code: 9720104

A thesis for the degree of
DOCTOR OF PHILOSOPHY

HA NOI - 2019


This study has been finished at Military Medical University.

Academic Supevisor:
1. Vu Quang Vinh PhD., A/Prof

2. Tran Van Anh PhD., A/Prof

Reviewer 1:
Reviewer 2:

Reviewer 3:

This thesis will be defended at Military Medical University at .........

This thesis may be found at:
1. Vietnam National Library
2. Military Medical University Library


1
INTRODUCTION
The prevalence of breast cancer has been increased and
became the most common cancer in woman. According to the World
Health Organization, breast cancer accounts for 25% of all cancers in
women and there are an estimated of 1.7 million new cases
worldwide each year. The management of breast cancer requires the
coordination of many specialities, not only to prevent or eliminate
the tumor but also to deal with the sequelae, the effects psychology
and quality of life of patients after treatment. Surgery treatment
(total masectomy) is considered the key to treat breast cancer.
However, it will lead to physical disability and may be possible to
have lymphatic edema on the side of the surgery in some patients,
causing discomfort to the patient because the local deformity of
lymphedema cannot be used to cover normal clothing. Patients
frequently have a feeling of their illness, loss of confidence in the
body, reduced fitness, fatigue and psychological decline ... thereby
affecting the quality of life of patients. Therefore, breast
reconstruction and treatment of lymphedema are important and
considered as a stage of treatment for breast cancer. Breast
reconstruction and treatment of lymphedema will help solve the

consequences and compliacations of breast cancer surgery, helping to
improve the woman confidence and the quality of life.
Breast reconstruction can be done by autograft or synthetic
materials or by combining both. In 1989, Koshima I. et al for the first
time successfully used deep inferior epigastric artery perforator flaps.
In 1994, Allen R. J. described for the first time deep inferior
epigastric artery are use in breast reconstruction. Because there are
many advantages such as relatively large tissue volume, good
aesthetics, minimally invase of flap removal, deep inferior epigastric


2
artery perforator flaps are increasingly used in breast reconstruction
surgery and is considered as the choice in some breast reconstruction
centers around the world.
Recently, treatment of lymphedema with lymph graft surgery
is common in many centers around the world with very positive
results. Instead of simple lymph nodes flap surgery, the simultaneous
implementation of breast reconstruction by abdominal flap with the
transfer of petiole ingot lymph nodes has been recently applied in
some centers around the world with encouraging initial results.
Since 1988 breast reconstruction surgery has been performed
by latissimus dorsi muscle flap. Recently, breast reconstruction
surgery has continuously developed with more difficult techniques
such as the deep inferior epigastric artery perforator by microsurgery.
However, there has been no report on the breast reconstruction by
simultaneous deep inferior epigastric artery perforator flaps and
vascularized groin lymph node flap transfer. Because the deep
inferior epigastric artery perforator flaps also have many
abnormalities in anatomaical variants, blood supply area, identifying

the main branch artery of this flap to safely lifting skin flap is still a
challenge to plastic surgeons. Therefore, the aims of this research
are:
1. To investigate the anatomical characteristics of deep inferior
epigastric artery perforator in Vietnamese adult.
2. To evaluate the effectiveness of deep inferior epigastric
artery perforator in treatment of sequelae of breast cancer
surgery.
3.


3
CHAPTER 1
LITERATURE REVIEWS
1.1.
SURGERY FOR BREAST CANCER
1.1.1. Radical mastectomy and extended radical mastectomy
1.1.2. Modified radical mastectomy
1.1.3. Breast conserving surgery
1.1.4. Skin - sparing mastectomy
1.1.5. Nipple and aerola - sparing mastectomy
1.2. BREAST RECONSTRUCTION AFTER BREAST
CANCER SURGERY
1.2.1. Indication and contraindication
1.2.1.1. Indicaion
1.2.1.2. Contraindication
1.2.2. Timing of breast reconstruction
1.2.2.1. Immediate breast reconstruction
1.2.2.2. Delayed breast reconstruction
1.2.3. Types of breast reconstruction

1.2.3.1. Reconstruction with prosthetic implants
1.2.3.2. Reconstruction with latissimus dorsi myocutaneous flap
1.2.3.3. Reconstruction with pedicled transverse rectus abdominis
myocutaneous flap
1.2.3.4. Reconstruction with free transverse rectus abdominis
myocutaneous flap
1.2.3.5. Reconstruction with superficial inferior epigastric artery
flap
1.2.3.6. Reconstruction with deep inferior epigastric perforators flap
1.3. LYMPHEDEMA AND BREAST RECONSTRUCTION
1.3.1. Upper extremity lymphedema after surgery for breast
cancer
1.3.2. Lymphedema after breast reconstruction
1.3.3. Effect of breast reconstruction on preexisting lymphedema
1.3.4. Combining autologous breast reconstruction and
vascularized lymph node transfer


4
1.4. DEEP INFERIOR EPIGASTRIC PERFORATOR FLAP
1.4.1. Definition of perforator, perforator flap and classification of
perforator
1.4.1.1. Definition of perforator, perforator flap
1.4.1.2. Classification of perforator
1.4.2. Vascular anatomy, nerve anatomy of deep inferior
epigastric perforator flap
1.4.2.1. Arterial system
1.4.2.2. Nerve innervation
1.4.3.1. Arterial perfusion
1.4.3.2. Venous drainage

1.4.4. Methods for the examination of deep inferor epigastric
artery perforator
1.4.4.1. Doppler sonography
1.4.4.2. Fluorescent angiography
1.4.4.3. Multidetector computed monography
1.4.5. Deep inferor epigastric artery perforator flap: Anatomical
study and clinical application in breast reconstruction
1.4.5.1. Anatomical study
The first study on anatomical characteristics of transverse
rectus abdominal muscle was conducted by Scheflan M. et al in
1983, after which it was further clarified with Hartramf C. R's
research. Following, some other authors have had more detailed
anatomical studies on deep inferior epigastric artery such as Boyd J.
B. et al 1984, Moon H. K. et al 1988, Tuominen H. P. in 1992. In
1993, Itoh Y. and Arai K. revealed that the deep epigastric artery
separated into two internal and external branches, and most of the
transverse branches originated from the outer branch. In 2004
Munhoz A. M. also showed in his study that the branch from the
outer branch of the lower epigastric artery should be choosen to
shorten the time of internal surgery. In 2006, Holm C. et al suggested
that there should be a change in the perfusion of the transverse


5
arterial branch deep of Harmanpf. Thus, the anatomical studies do
not yet have uniformity in the perfusion partition of the flap, the
division of branches of the deep epigastric artery and its perforators
distribution. In Vietnam, there are several authors describing the
epigastric arterial system but have not described in detail the
characteristics of the transverse branches ... Therefore, in this topic,

we will study the characteristics anatomy, perfusion of deep
epigastric perforators.
1.4.5.2. Clinical application of deep inferior epigastric artery
perforator in breast reconstruction
In 1989, Koshima I. et al for the first time used the deep
inferior epigastric artery perforator flaps to cover the oropharyngeal
defect. By 1992, Allen R. J. et al described the application of a deep
inferior epigastric artery perforator in breast reconstruction. In 1994,
Bloodel P. N. et al performed the DIEP flap with two vascular prongs
in breast reconstruction with good results. In 2004, Guerra A. B. et al
reported using 280 strips of DIEP to reconstruct breast and both sides
with a success rate of 98.2%. Also, in this year Gill P. S. and CS
reported the results of 758 flap DIEP in breast reconstruction within
10 years with a success rate of up to 97%. In Vietnam, DIEP has
been used in breast reconstruction since 2007 and there have been
some publications about the result of this flap. However, the number
of ties used in these publications is quite modest but also shows
encouraging results, with a success rate of 80%.
1.4.5.3. Using deep inferior epigastric artery perforator in
combination with inguinal vascularized groin lymph node flap
transfer to reconstruct breast and treat lymphedema simultaneously
The combination of breast reconstruction and treatment of
upper limb edema after breast cancer surgery by inguinal
vascularized groin lymph node flap transfer is first described by
Saaristo AM et al in 2012 with promising results on 9 patients. In
2013, Dancey A. et al reported 18 cases of using DIEP in


6
combination with inguinal vascularized groin lymph node flap

transfer with the rate of improvement of lymphatic edema symptoms
being 100% of cases. Another study of 2015 by Nguyen A. T et al
showed similar benefits in patients using combination of DIEP with
groin lymph node flap transfer to reconstruct breast and treat
lymphedema simultaneously. In 2016, De Brucker B. B. et al
reported 25 cases with a symptom improvement rate of 21/25 cases.
In 2017 Akita S. and et al reported 27 patients with lymphatic edema
after breast cancer surgery treated with inguinal lymph graft, of
which 13 patients had breast reconstruction combined with DIEP
flap. The author found that in the group using DIEP flap combined
groin lymph node flap transfer, lymphatic function improved
compared to patients with groin lymph node flap transfer only.
Chang E. I. and CS in a 2018 report also showed the reliability and
effectiveness of simultaneous use of DIEP and inguinal lymph graft.
At the same time, the author also provided the role of inguinal lymph
nodes examination by means of preoperative diagnostic imaging,
especially MDCT. In Vietnam so far, there have been no reports of
combining the use of DIEP flap and inguinal lymph node grafting in
breast reconstruction and simultaneous treatment of lymphedema.
CHAPTER 2
OBJECTS AND METHODS

2.1. OBJECTS
2.1.1. Anatomical study
2.1.1.1. Anatomical cadaver study
Anatomical characteristics of the deep epigastric arteries in
the abdomen were studied on 20 fresh cadavers of adult Vietnamese
who are preserved cold - 300 C at the Anatomy Department of Ho
Chi Minh University of Medicine and Pharmacy.
- Selection criteria: Vietnamese fresh cadavers ≥ 18 years old,

preserved in cold, non-injury in the lower abdomen or andominal
middle incision without injury of low abdominal quarant.


7
- Exclusion criteria: previous surgery at the abdominal wall or any
disease that change anatomical structure of the vascular system
provided for the lower abdominal wall.
2.1.1.2. Anatomical study of patients
- Multiple detector computed tomography (MDCT) before surgery
to examine the anatomical characteristics of deep epigastric vascular
bundles and perforators.
- Fluorescence intra-arterial injection to evaluate blood supply of
flaps.
2.1.2. Clinical research
30 female patients with breast reconstruction surgery by
deep inferior epigastric artery perforator flap after breast cancer
surgery were studied at Binh Dan Hospital, City Hospital of
Medicine and Pharmacy University, Ho Chi Minh City and National
Burn Hospital from November 2011 to September 2016.
2.1.2.1. Selection criteria
- Patients who undergo breast cancer surgery with or without
lymphadenopathy complication desired to reconstruct breast by
autologous graft.
- There is an excess of skin and fat in the low abdomen.
2.1.2.2. Exclusion criteria
- There is not excess of skin and fat in the low abdomen.
- Previous surgery with abdominal skin flap, deep inferior epigastric
artery perforator flap or abdominal reconstruction surgery.
- Infectious condiditon of the abdominal wall.

- Patients with lesions, scars in the abdominal area, in which can not
find the branch of deep epigastric artery to perform DIEP flap.
- Patients have lower lymphatic edema, intact bilateral inguinal
lymph nodes (for breast reconstruction combined with inguinal
lymph graft).
2.2. MEANS AND MATERIAL
2.2.1. Means and materials for anatomical study


8
2.2.2. Means and materials for clinical research
2.3. METHODS
2.3.1. Anatomical characteristics study of the deep epigastric
artery perforators
2.3.1.1. Objectives
2.3.1.2. Methods
Descriptive cross-sectional study.
2.3.1.3. Steps
- Investigating the characteristics of deep epigastric vascular bundles
and perforators
+ Classical dissection on cadavers: Fix the body in the supine
position. The skin flap is designed as rhombic shape with the lower
part of the incision on the pubic bone as in clinical practice. Draw
1/2 circles which the center is umbilicus with radius of 2 cm, 4 cm, 6
cm, 8 cm. This circle is below the umbilical cord to determine the
distribution of the perforators. One-third middle inguinal incision
was made to explore the deep epigastric arteries. No. 20 catherter is
inserted in the vein, fixed and injected with Barisulphat contrast dye
mixed with blue Methylene into the vein (10 ml green Methylene /
100 ml Barrisulphat). Observe the drug infiltration of skin flap. The

cadaver is cold preserved for 24 hours. After 24 hours, the flap was
dissected from outside to inside to evaluate the characteristics of
deep epithelial vascular bundles and perforators such as: original,
number, diameter, length, position, distribution.
+ Blood vessels was examined before surgery by multiple detector
computed tomography (MDCT) (n = 19 with Toshib's MDCT 128
Aquilon, carried out after injecting 1.5 ml / kg of Ultravist contrast
material 300 with 4 ml / sec speed into peripheral veins. Position,
origin, pathway and anatomical changes of transverse branches, deep
epigastric artery, deep epigastric vein was studied in over 19 patients.
- Evaluate the blood supply of perforator for flap and vascular
networks


9
+ Skin flap angiography was performed after surgery (n = 8) with
Toshiba digital radiograph with parameters 100 Kv, 100 mA at the
Medic Medical Diagnostic Center.
+ MDCT scan of skin flap was performed after dissect on cavaders
(n = 12) with MDCT 128 Aquilon Toshiba to investigate the inner
circuit network at the Medic Medical Diagnostic Center.
+ The perfusion was assessed during surgery with fluoresceine (n =
15) after an isolated vein dissection. Intravenous fluoresceine 15mg /
kg weight was performed after a negative test. Take a picture of the
flap in the dark before injecting and after injecting 20 minutes under
the Wood light.
2.3.2. Clinical research
2.3.2.1. Objectives
2.3.2.2. Methods
Cases series study.

2.3.2.3. Steps
- Preoperative examination:
- Surgical procedure:
Indication and contre indication:
Design flap:
Anesthesia:
Patient positioning:
Surgical steps:
- Recipient area preparation:
+ The breast preparation: remove the old scar, the damage from
radiation therapy and send it to do pathological evaluation. The area
to receive the flap was dissect to the muscle layers, up to the groove
on the new breast, down to the groove under the new breast. In the
case of lymph grafting, the cavity will be removed to the armpit to
prepare the graft site.


10
+ Blodd vessles preparation: The internal mammary artery and vein
or the external one, and the head vein are also surgically used as a
good source of grafting when it is not affected by radiation.
- Flap dissection:
+ Breast reconstruction, not accompanied by upper limb
lymphedema (19 patients), use of DIEP flap alone: make incision to
facial layer, skin flap is lifted from the outer to the outer edge of the
rectus abdominis. It must be careful to avoid hurting the major
perforator. Select 1 or 2 major perforators with accompanied veins,
dissect along them to the starting position is the lower epigastric
bundle, loosen and cut the other perforators. The rectus abdominis
muscle is opened vertically to dissect the lower epigastric vein to the

original side to ensure that the vein is long enough.
+ Breast reconstruction in combination with upper limb edema (11
patients), use the DIEP flap with transfer of inguinal lymph nodes:
The part of the inguinal lymph nodes is dissected along the
reconstructed breast, taken from the skin to facial layer, including
inguinal lymph nodes. Superficial epigastric artery or external
pudendal artery with inguinal lymph nodes flaps were dissected.
- Microsurgerical anastomosis and breast reconstruction:
+ Microsurgerical anatomosis: flap will be temporarily fixed; the
vascular anastomosis was performed with 9.0-10.0 prolene under
microsurgery.
+ In the case of inguinal lymp graft: the lymph node and surrounding
tissue will be fixed to the armpit after peeling the epidermis.
+ Breast reconstruction: The flap is calibrated to create new breasts
based on opposing breasts and check again in the half-sitting posture.
The flap is fixed 2 layers after placing the drain.
- Check the flap circulation by observing the skin color of flap,
Doppler ultrasound examination. Tape the incision.
Post-operation care:
2.3.2.4. Monitoring indicators and methods for evaluating results


11

 Monitoring indicators:
 Evaluating postoperative results:
 Evaluation of breast reconstruction surgery results:
 Shor-term follow-up (within 6 months):
 Good: Completely living flaps, well-scarred incisions
without inflammation.

 Moderate: the flap has a condition of nourishment or partial
necrosis at the end of the end or flap, fat necrosis, hematoma or
wound infection.
 Poor: Necrotic flap over 1/3 of area or whole, must be
filtered and replaced by another method.
 Long-term follow-up (after 6 months):
 Good: The flap is soft, the color is in harmony with the
surrounding, the breast volume is proportional to the opposing
breast, the breast is clear and symmetrical, the scars are small, the
abdomen scar is small, the abdominal shape slim, not leaving
sequelae at the place for flap.

Moderate: The flap is slightly soft, the color is less
harmonious than the surrounding, the breast volume is less
disproportionate than the opposing breast, the breast is clear but less
or disproportionate compared to the opposing breast, the scar is bad ,
in breast or abdominal wall, less distorted abdominal shape,
abdominal wall where the flap has a pasty state, reduced sensation..
 Poor: The flap is not soft, the color is not in harmony with
the surrounding, the volume of breast imbalance is clear compared to
the opposing breast, the underside of the breast is unclear, the scar in
the breast orin the abdomen is convex or hypertrophy, distinctly
deformed abdominal form, herniated abdominal wall, loss of feeling
of abdominal wall.
 Evaluation of the results of lymph node transplantation after 6
months according to the following levels:


12
 Good: Soft edema, relieve pain, reduce the circumference of

the hand, the side of the legs will not match.
 Medium: Soft limbs relieve pain, the circumference of the
hands remains unchanged, the legs on the sides do not match.
 Poor: Hands fit better or / and match the right leg for lymph
nodes.
2.3.3. Statistical analyses
Statistical analyses were performed with Stata 13.0.
CHAPTER 3
STUDY RESULT
3.1. STUDY RESULT OF ANATOMY
3.1.1. Characteristics of deep epigastric arteries vessels and
perforators
3.1.1.1. Classical dissection on cadavers:
- Characteristics of deep epigastric arteries: Results of all DIEA are
derived from external pelvic arteries. They located behind rectus
abdominis 77.5% or inside this muscle 22.5%. The average diameter
of DIEA is 2.2 ± 0.2 mm. DIEA with 1 main branch is 52.5%, 2 main
branches are 42.5% and 3 branches are 5%.
Table 3.4. Characteristics of deep inferior epigastric artery
perforators
Characteristics
Right
Left
Common
Dominant
(n=88)
(n=89)
(n=177)
(n=40)
Dimension

± SD (mm)
- Diameter
0,8 ± 0,2
0,7 ± 0,2
0,7 ± 0,2
1,0 ± 0,1
- Length
45,6 ± 11,6 45,9 ± 12,0
45,8 ± 11,8
44,3 ± 13,8
Starting point
- From lateral branch 12 (13,6%) 21 (23,6%)
33 (18,6%)
5 (12,5%)
- From medial branch 13 (14,8%) 25 (28,1%)
38 (21,5%)
11 (27,5%)
- From arterial trunk
63 (71,6%) 43 (48,3%) 106 (59,9%)
24 (60%)


13
Direction
- Straight
41 (46,6%) 31 (34,8%)
72 (40,7%)
24 (60%)
- Oblique
47 (54,4%) 57 (64,0%) 104 (58,8%)

16 (40%)
- Paramuscular
0 (0%)
1 (1,1%)
1 (0,6%)
0 (0%)
Distance ± SD (mm)
- To ombilic
37,9 ± 18,2 30,8 ± 15,4
34,4 ± 17,2 29,3 ± 13,2
- To x-axis
25,2 ± 16,4 22,5 ± 15,1
23,8 ± 15,8
16,2 ± 7,1
- To y-axis
25,9 ± 13,9
19,1 ± 9,8
22,5 ± 12,4 23,4 ± 13,1
Distribution in the half circle from the umbilical cord
0 - 2 cm
19
36 (40,5%)
55 (31,1%)
16 (40%)
(21,6%)
<2 - 4 cm
27
29 (32,6%)
56 (31,6%)
13 (32,5%)

(30,7%)
<4 - 6 cm
32
20 (22,5%)
52 (29,4%)
11 (27,5%)
(36,4%)
<6 - 8 cm
10 (11,4%)
4 (4,5%)
14 (7,9%)
0 (0%)
Position
- Medial row
49
57 (64,0%) 106 (59,9%)
24 (60%)
(55,7%)
- Lateral row
39
32 (36,0%)
71 (40,1%)
16 (40%)
(44,3%)
Table 3.5. Direction of perforators on medial row và lateral row
Direction
Position
Medial row (n=106)
Lateral row (n=71)
Straight

21 (19,8%)
51 (71,8%)
Oblique
84 (79,3%)
20 (28,2%)
Paramuscular
1 (0,9%)
0 (0%)
3.1.1.2. On MDCT of patients
19 patients were examined in the vascular system of the flap
before surgery by MDCT and identified some results as follows:


14
- DIEA located behind muscle 81.6%, inside muscle 18.4%. DIEA
has 1 branch 68.4%, 2 branches 28.9% and 3 branches 3.6%. The
diameter at the base is 2.0 ± 0.2 mm.
- Number of perforators with diameter ≥ 0.5mm of deep epigastric
artery: 157 transverse branches / 38 DIEA, average 4 transverse
branches / 1 DIEA.
Table 3.9. Characteristics of deep inferior epigastric artery
perforators on the multidetector computer tomography
Characteristics
Right
Left
Common
Dominant
(n=80)
(n=77)
(n=157)

(n=38)
Dimension ± SD
(mm)
- Diameter
0,9 ± 0,3
0,9 ± 0,3
0,9 ± 0,3
1,2 ± 0,1
Direction
intramuscular
- Straight
38 (47,5%) 37 (48,1%) 75 (47,8%) 21 (55,3%)
- Oblique
40 (50%)
40 (52,0%) 80 (51,0%) 17 (44,7%)
- Paramuscular
2 (2,5%)
0 (0%)
2 (1,3%)
0 (0%)
Direction to skin
- Lateral
45 (56,3%) 43 (55,8%) 88 (56,1%)
9 (23,7%)
- Straight
9 (11,3%)
7 (9,1%)
16 (10,2%)
0 (0%)
- Medial

4 (5%)
6 (7,8%)
10 (6,4%)
1 (2,6%)
- Lateral and
21 (26,3%) 17 (22,1%) 38 (24,2%) 25 (65,8%)
medial
- Lateral and
0 (0%)
2 (2,6%)
2 (1,3%)
1 (2,6%)
straight
- Straight and
0 (0%)
1 (1,3%)
1 (0,6%)
0 (0%)
medial
- Lateral, straight
1 (1,3%)
1 (1,3%)
2 (1,3%)
2 (5,3%)
and medial
Subfascial
- No
58 (72,5%) 57 (74,0%)
115
18 (47,4%)

(73,3%)
- Yes
22 (27,5%) 20 (26,0%) 42 (26,8%) 20 (52,6%)


15
Distance
± SD (mm)
- To ombilic
34,5 ± 14,1 33,8 ± 15,0 34,2 ± 14,5 28,5 ± 11,7
- To x-axis
17,9 ± 12,9 21,0 ± 13,2 19,4 ± 13,1 17,3 ± 11,1
- To y-axis
26,5 ± 14,3 23,8 ± 13,7 25,2 ± 14,0 20,6 ± 10,4
Distribution of perforators in the half circle from the umbilical cord
0 - 2 cm
14 (17,5%) 16 (20,8%) 30 (19,1%) 8 (21,1%)
< 2 - 4 cm
37 (46,3%) 34 (44,2%) 71 (45,2%) 22 (57,9%)
< 4 - 6 cm
27 (33,8%) 23 (29,9%) 50 (31,9%) 8 (21,1%)
< 6 - 8 cm
2 (2,5%)
4 (5,2%)
6 (3,8%)
0 (0%)
3.1.2. The blood supply of perforators for flap
The skin flaps from cadavers will be separated for
angiography and MDCT. The skin flaps which was taken
angiography (n = 8), showed richly blood supply. There is a

connection between perforator with different blood supply areas. The
results of MDCT from skin laps (n = 12) clearly showed the 3dimensional spatial structure of the perforator, the connection
between the lateral branches, the connection across the line. Middle
white has also been recorded.
Fluorescent angiography peroperative with
fluoresceine
Table 3.13. Characteristics of blood supply for flap on
fluorescent angiography
Characteristics
Number
Ratio %
Flap fluorescence (n=15)
- Zone I

15

100%

- Zone II

15

100%

- Zone III

15

100%

- Zone IV

8

53,3%

3.2.
STUDY RESULT OF CLINIC
3.2.1. Clinical characteristics of patients
Table 3.14. Distribution of patient age


16
Age
< 40

Number
4

Ratio %
13,3%

40 - 60

23

76,7%

≥ 60

3

10%

± SD

49,1 ± 8,7
(31 - 66)
3.2.2. Characteristics deep inferior epigastric artery perforators
on hand held Doppler device
3.2.3. Characteristics of breast reconstruction
Table 3.22. Characteristics of dimension of flap
Dimension of
Mean
Standard
Minimum
Maximum
flap (cm)
deviation
Length
35,1
5,6
14
44
Width

12,5

1,6

9

16

3.2.4. Result of breast reconstruction
Table 3.29. Early recipient site complications
Postoperative complication
Number (n)
Ratio (%)
Bleeding
1
3,3%
Partial flap loss
0
0%
Total flap loss
2
6,7%
Flap poor nourished
0
0%
Fat necrosis
2
6,7%
Seroma
0
0%
Infection
0
0%

Total
5
16,7%
In this study, there were 2 cases of total necrosis flap due to
venous embolism on the 3rd and 4th days after surgery and 1 case of
surgical wound infections (3.3%). Thus, the general complication
rate of breast reconstruction is 20%.


17
Table 3.34. Short-term outcome
Short-term outcome
Number (n)
Ratio (%)
Good

24

80%

Moderate

4

13,3%

Poor

2

6,7%

Table 3.35. Long-term outcome
Long-term outcome
Number (n)
Ratio (%)
Good
24
85,7%
Moderate
4
14,3%
Poor
0
0%
3.2.5. Result of lymphedema treatments
Table 3.36. The change of upper limb circumference
Time
Upper limb circumference (cm)
10 cm proximal
to the elbow

The elbow

10 cm distal
to the elbow

Before surgery (n=11)

30,6 ± 3,3

28,1 ± 4,0

25,2 ± 4,6

1 month after surgery
(n=11)
3 months after surgery
(n=11)
6 months after surgery
(n=11)
12 months after surgery
(n=9)
24 months after surgery
(n=3)
p value *

30,2 ± 3,3

27,9 ± 3,9

25,0 ± 4,6

29,9 ± 3,1

27,6 ± 3,7

24,8 ± 4,4

29,3 ± 3,0

27,2 ± 3,7

24,5 ± 4,2

29,1 ± 2,9

26,6 ± 2,9

24,6 ± 3,7

27,8 ± 1,9

25,5 ± 2,2

23,9 ± 3,7

<0,001

0,001

0,014

* ANOVA test


18
Table 3.37. The reduction rate of the upper limb
Time
The reduction rate of the upper limb lymphedema

compared the upper limb opposite (%)
10 cm proximal to
The elbow
10 cm distal to the
the elbow
elbow
Before surgery
11%
10%
11%
(n=11)
1 month after
25%
22%
26%
surgery (n=11)
3 months after
47%
45%
40%
surgery (n=11)
6 months after
58%
69%
56%
surgery (n=11)
12 months after
61%
74%
41%

surgery (n=9)
p value *
<0,001
0,001
0,014
Table 3.40. Outcome of lymphedema treatments
Outcome
Number (n=11)
Ratio %
Good
Moderate
Poor

10
1
0

90,9%
9,1%
0%

CHAPTER 4
DISCUSSION
4.1. THE ANATOMY OF THE BLOOD SUPPLY TO THE
FLAP
4.1.1. Deep inferior epigastric artery
4.1.2. Deep inferior epigastric venous
4.1.3. Deep inferior epigastric artery perforators
Number of the perforator

19
In the study of cadavers and MDCT, we only evaluated the
perforators with diameter ≥ 0.5 mm: the average numbers of
perforatora is 4.4 and 4 per DEA in the skin flap respectively in low
hafl abdominal rhombus. Boyd JB, Itoh Y. and CS, Chawla K.,
Schaverien M. also evaluated the perforators (≥ 0.5 mm diameter) of
DIEA in total abdominal rhombus with an average result of 6,5 6,8,
5,8 and 4 trans-branch/1 DIEA.
Location and distribution
Like other authors, we found that the perforartors of DIEA
are distributed in 2 rows in when the rectus abdominis sheath: outer
and inner row with the number of 104 (59.43%) and 71 (40.57%)
respectively. They mainly located within a radius of 0 – 40 circles
from the umbilical cord as same as results of other authors.
Length and diameter
The most perforators in our cadaver’s study have an average
diameter of 1 mm (0.8 to 1.2 mm), an average length of 43, 78 mm
(25 - 80 mm).
Direction
When investigating the direction of the inter-muscular
branches, we found that the perforators of inner line have often
cross-direction in the muscle (79.80%) while the outer line often
have straight direction (74.65%) This is also consistent with other
studies.
4.1.4. Evaluation of blood supply for flap and vessels network in the
flap by angiography and multi detector computer topography of skin
flap after dissect on cadavers and fluorescent angiography
peroperative with fluoresceine.
4.2. CLINICAL APPLICATION

4.2.1. Reason for choosing deep inferior epigastric artery
perforator
We selected the DEIP flap in breast reconstruction for the
following reasons: DIEP flap provides a large volume of tissue, skin


20
color and tissue density like the opposing breast. Minimum damage
to the flap and scar area where the flap is easy to hide. In anatomical
research shows that the blood supply is stable, the blood supply area
of the peforators is good enough to ensure safety for blood clotting.
It also has better aesthetic view in the abdomen. This method also
allows to combine lymph graft surgery in case of hand lymphedema
after breast cancer.
4.2.2. Combination of breast reconstruction and treatment of
upper limb edema
Author Granzow J. W et al used DIEP / inguinal grafting flap
and perfomed the vascular anatomosis with internal mammary artery
[104]. In contrast, like Dancey A. et al, Saarissto A. M et al, we
performed the vascular anastomosis with internal thoracic artery - in
most cases without any complications. All patients have positive
improvements such as: lighter arms, softer, less painful areas. As
same by other studies, the improvements began 1 month after
surgery [27], [34]. Initial results identified decreas of edema, average
circumference is 74% after 24 months.
4.2.3. Select the suitable perforator - the role of image
assessements: Doppler ultrasound and multi detector computer
topography
4.2.4. The determinants of selecting the perforator for the pedicle
of flap

4.2.5. Selecting safety approach to perforator dissection:
subfascia or under fascia
4.2.6. Using 1 perforator or many perforators
4.2.7. Dissection one or two pedicles
4.2.8. Peroperative evaluation of blood supply for flap
4.2.9. Selecting the recipient pedicles - The effects of
radiotherapy on the selection of the recipient pedicles
4.2.10. The necessity to remove rib cartilage
4.2.11. One or two anastomosis: The role of SIEV


21
4.2.12. Breast reconstruction with one or two aesthetic unit
4.2.13. Failure and complication
The failure of DIEP flaps is often due to venous problems,
venous congestion or insufficiency is from 1.6 to 36.5%, the rate of
flap failure is 0-9,6%. Gill P. S. et al performed 758 DIEP flaps for
breast reconstruction, 5.9% of patients had to return to the operating
room because of complications of flap. The rate of partial necrotic
necrosis is 2.5%, total necrosis is 0.5%. The complications of vein or
vein anastomosis are 8 times higher than artery problems.
Nahabedian MY et al studied on 88 breast reconstruction patients
with DIEP flap (110 flaps), the total rate of necrosis of the flap was
2.7%, fat necrosis was 6.4%, venous congestion 4.5%. Lie KH et al
performed metal analysis study with 17096 branches of deeppenetration arteries reported in 693 articles published from 1989 to
2011, found 152 cases of total failure. The reasons of 67 failure cases
are: 40% by vein (27/67), 28% by arteries (19/67) and 21% by
mechanics (vessles bundle pressure, hematomas). Hamdi M. et al
with more than 1200 cases of breast reconstruction using DIEP flap,
the rate of re-operation due to vascular anatomosis is 5%, of which

the overall rate of necrosis of the flap is 1%, the rate of partial
necrosis and/or fat necrosis is 8% [118]. In our study, the overall
incidence of necrosis was 6.7%, 0%- of partial necrosis, 6.7% fat
necrosis, 6.7% intravenous congestion. Our two cases of flap failure
were caused by venous complication and had to remove flap. In
which one case was closed the incision and the other one converted
the method of regeneration with latissimus dorsi flaps.


22
CONCLUSION
From study on 20 fresh cadervers and on 30 breast reconstruction
patients, we concluded as follows:
1. Anatomical study:
 Classic dissection on the cadavers
 Most deep epigastric arteries go up behind the rectus
abdominis (77.5%) and divide 3 types of branches: one main brach, 2
main branches, or 3 main branches. In which mainly one main
branch (52.5%) and 2 main branches (42.5%).
 The diameter at the epigastric arteries orginal is 2.2 ± 0.2
mm and the length from the orginal of the lower epigastric artery to
the perforator is 14.9 ± 3.5 mm.
 97.5% of DIEA have 2 veins, these two veins often have
bridges and combine to a common vein (92.5%) before drain into the
external pelvic vein.
 There average number of perforators is 4.4 with diameter ≥
0.5 mm per 1 DEA. The perforators have an average diameter of 0.7
± 0.2 mm and an average length of 45.8 ± 11.8 mm.
 The dominant perforators have an average diameter of 1.0 ±
0.1 mm and an average length of 44.3 ± 13.8 mm.

 Most branches located within a radius of 0 - 4 cm in the half
circle from the umbilical cord (72.5%).
 On the front side of the rectus abdominis sheath, the
perforator diceided in the inner line (59.9%) and the outer line
(40.1%). Most of the perforators of the inner line run cross through
the muscle (79.3%), whereas the perforators of the outer line are
mostly straight through the muscles (71.8%).
 Preoperative MDCT: MDCT (19/30 cases) also recorded
most of DIEA run behind the rectus abdominis (81.6%) and also
divided into 3 type of branches: 1 main branch (68.4%), 2 main
branches (28.9 %) and 3 main branches (2.6%). The diameter at the
orginal of DIEA is 2.0 ± 0.2 and the length of the DIEA from the root


23
to the perforator is 140.2 ± 22.2 mm. 100% of cases have 2 deep
epigastric veins and 2 veins that combine the common body before
drain into the external pelvic vein in most cases (78.9%). There are
157 perforators (diameter ≥ 0.5mm) above 38 DMTVDS (2-6
perforators per 1 DEA) with an average diameter of 0.9 ± 0.3 mm.
Most of perforators mainly located within the radius of 0 - 4 cm of
the low half circle from the umbilical cord (79%).
 The blood supply to the flap of the perforators and the
vascular network in the flap on the angiography, MDCT of the
flap after dissect on the cadaver:
 The X-ray and MDCT images showed that the skin flap
shows a very rich connection between perforators for blood supply.
This indicates a high safety when using flap with 1-3 dominant
perforators.
 There were 15/30 patients were performed intraoperative

injection of fluoresceine, all cases were absorbed by the dye from
region I to region III, more than half of them were soaked to region
IV.
2. Clinical application in the breast reconstruction, the breast
reconstruction combined with inguinal lymph graft:
 There are 30 cases of breast reconstruction: 19 cases of DIEP
flaps only, 11 cases of DIEP flaps combined with inguinal lymph
graft to treat lymphedema.
 By Doppler ultrasound prior to surgery, most cases have 2-3
perforators in each side of the DIEA and mainly located in the radius
of 0 - 4 cm of the half circle with the umbilical cord.
 The DIEP lap is used with 1 or 2 perforators.
 The recipient arteries are internal thoracic arteries (46.7%)
and the thoracic arteries (46.7%). The vein is also predominantly the
dorsal thoracic (43.3%) and the inner thoracic vein (30%). Most
cases only performed one veinous anatomosis (63.3%).