VI Breast Reconstructive Course on CadaverAlicante, SpainOctober 4-5, 2013

Course Director:José F. Salvador Sanz, M.D., Spain

International Faculty:Jaume Masià, M.D., SpainThomas Schöeller, M.D., DeutschlandDr. Michel Saint-Cyr, M.D., USA

VI Breast Reconstructive Course on CadaverAlicante, SpainOctober 4-5, 2013

Course Director:José F. Salvador Sanz, M.D., Spain

International Faculty:Jaume Masià, M.D., SpainThomas Schöeller, M.D., DeutschlandDr. Michel Saint-Cyr, M.D., USA

Local Faculty:V. Almenar García, M.D., SpainF. Terol Calpena, M.D., SpainJ. A. Robles Laguna, M.D., SpainE. Lorda Barraquer, M.D., SpainA. Novo Torres, M.D., SpainJ. J. Aparicio, M.D., Spain

Dissection Room Technicians:A. Sanchez de la Blanca Mesa, SpainP. Ortuño Hernández, Spain

Local Faculty:V. Almenar García, M.D., SpainF. Terol Calpena, M.D., SpainJ. A. Robles Laguna, M.D., SpainE. Lorda Barraquer, M.D., SpainA. Novo Torres, M.D., SpainJ. J. Aparicio, M.D., Spain

Dissection Room Technicians:A. Sanchez de la Blanca Mesa, SpainP. Ortuño Hernández, Spain

The VIthAnnual BREAST RECONSTRUCTIVE COURSE ON CADAVER

DISSECTION COURSE GUIDE

TABLE OF CONTENTS

Flap Name Page

Deep Inferior Epigastric Perforator (DIEP) Flap 3 Superficial Inferior Epigastric Artery (SIEA) Flap 7 Superior Gluteal Artery Perforator (S-GAP) Flap 11 Thoracodorsal Artery Perforator (TDAP) Flap 18 Lateral Intercostal Artery Perforator (LICAP) Flap 23 Transverse Myocutaneous Gracilis (TMG/TUG) Flap Lymph-node adiposal flap transfer

VI BREAST RECONSTRUCTION COURSE ON CADAVERALICANTE 4-5 OCTOBER, 2013

DEEP INFERIOR EPIGASTRIC PERFORATOR (DIEP) FLAP

VI BREAST RECONSTRUCTION COURSE ON CADAVERALICANTE 4-5 OCTOBER, 2013

Flap: Deep Inferior Epigastric Perforator (DIEP)

Tissues available: cutaneous __________________________________________________________________Vascular Anatomy: deep inferior epigastric artery perforators __________________________________________________________________Innervation: intercostal nerves __________________________________________________________________Flap Dimensions: 15 x 30 cm __________________________________________________________________Advantages: no muscle sacrifice, acceptable donor site scar, ample available tissue __________________________________________________________________Disadvantages: technically demanding, anatomic variations, less perfusion than variant which includes rectus muscle and multiple perforators (TRAM, msTRAM) __________________________________________________________________Things to note: single perforator larger than 1.5mm adequate; spare intercostal motor nerves __________________________________________________________________Notes:

VI BREAST RECONSTRUCTION COURSE ON CADAVERALICANTE 4-5 OCTOBER, 2013

NEUROVASCULAR ANATOMY

VI BREAST RECONSTRUCTION COURSE ON CADAVERALICANTE 4-5 OCTOBER, 2013

VI BREAST RECONSTRUCTION COURSE ON CADAVERALICANTE 4-5 OCTOBER, 2013

VI BREAST RECONSTRUCTION COURSE ON CADAVERALICANTE 4-5 OCTOBER, 2013

SUPERFICIAL INFERIOR EPIGASTRIC ARTERY (SIEA) FLAP

VI BREAST RECONSTRUCTION COURSE ON CADAVERALICANTE 4-5 OCTOBER, 2013

Flap: Superficial Inferior Epigastric Artery (SIEA)

Tissues available: cutaneous ___________________________________________________________________Vascular Anatomy: superficial inferior epigastric artery ___________________________________________________________________Innervation: noneFlap Dimensions: 15 x 20 cm ___________________________________________________________________Advantages: no muscle sacrifice or fascial incision required, acceptable donor site scar, ample available tissue ___________________________________________________________________Disadvantages: technically demanding, anatomic variations, seldom present greater than 1.5mm in diameter, limiting its use ___________________________________________________________________Things to note: poor perfusion across midline; may have added blood supply via SCIA (see groin flap) or adding a DIEP pedicle ___________________________________________________________________Notes:

VI BREAST RECONSTRUCTION COURSE ON CADAVERALICANTE 4-5 OCTOBER, 2013

ARTERIAL SUPPLY TO SIEA FLAP

VI BREAST RECONSTRUCTION COURSE ON CADAVERALICANTE 4-5 OCTOBER, 2013

SUPERIOR GLUTEAL ARTERY PERFORATOR (S-GAP) FLAP

VI BREAST RECONSTRUCTION COURSE ON CADAVERALICANTE 4-5 OCTOBER, 2013

Flap: S-GAP Flap

Tissues available: skin, fat, (muscle) ___________________________________________________________________Vascular Anatomy: superior gluteal artery(2-3mm) and vein(3-4mm); pedicle 6 cm ___________________________________________________________________Innervation: no sensory nerve with flap ___________________________________________________________________Flap Dimensions: 13x30cm ___________________________________________________________________Advantages: available donor site in most patients; hidden donor scar; mimicks buttock lift ___________________________________________________________________Disadvantages: must harvest in lateral or prone position, sometimes necessitating position change during case; contour deformities may require revision and contralateral contour procedures; donor site seromas common; ___________________________________________________________________Things to note: if fat distribution is inferior, then I-GAP preferred. Upper hip tissues can be carried on the SGA or lumbar vessels and CTA or MRA may aide flap design. ___________________________________________________________________Notes:

VI BREAST RECONSTRUCTION COURSE ON CADAVERALICANTE 4-5 OCTOBER, 2013

VI BREAST RECONSTRUCTION COURSE ON CADAVERALICANTE 4-5 OCTOBER, 2013

GT GREATER TROCHANTERPSIS POSTEROSUPERIOR ILIAC SPINEC COCCYXP MEDIAL POINTF 2/3 POINT

VI BREAST RECONSTRUCTION COURSE ON CADAVERALICANTE 4-5 OCTOBER, 2013

THORACODORSAL ARTERY PERFORATOR (TDAP) FLAP

VI BREAST RECONSTRUCTION COURSE ON CADAVERALICANTE 4-5 OCTOBER, 2013

Flap: TDAP Flap

Tissues available: skin, (muscle) ___________________________________________________________________Vascular Anatomy: thoracodorsal artery(2-4mm), vein (2-5mm); pedicle length 8 cm, which can be lengthened by including subscapular trunk; ___________________________________________________________________Innervation: thoracodorsal nerve (motor), lateral cutaneous branches of the intercostal nerves(sensory) ___________________________________________________________________Flap Dimensions: 9x22 cm (primary closure) ___________________________________________________________________Advantages: large size, long pedicle (15 cm); ___________________________________________________________________Disadvantages: need lateral positioning; large scar; ___________________________________________________________________Things to note: better for lateral defects and partial breast reconstruction ___________________________________________________________________Notes:

VI BREAST RECONSTRUCTION COURSE ON CADAVERALICANTE 4-5 OCTOBER, 2013

VI BREAST RECONSTRUCTION COURSE ON CADAVERALICANTE 4-5 OCTOBER, 2013

VI BREAST RECONSTRUCTION COURSE ON CADAVERALICANTE 4-5 OCTOBER, 2013

LATERAL INTERCOSTAL ARTERY PERFORATOR (LICAP) FLAP

VI BREAST RECONSTRUCTION COURSE ON CADAVERALICANTE 4-5 OCTOBER, 2013

Flap: LICAP Flap

Tissues available: skin, (muscle) ___________________________________________________________________Vascular Anatomy: lateral intercostal artery(1-1.5mm), vein (1-2mm); pedicle length 15 cm ___________________________________________________________________Innervation: cutaneous branches of the intercostal nerves(sensory) ___________________________________________________________________Flap Dimensions: 24 x 14 cm (primary closure) ___________________________________________________________________Advantages: large size, long pedicle (15 cm); ___________________________________________________________________ Disadvantages: need lateral positioning; large scar; ___________________________________________________________________Things to note: better for lateral defects and partial breast reconstruction ___________________________________________________________________Notes:

VI BREAST RECONSTRUCTION COURSE ON CADAVERALICANTE 4-5 OCTOBER, 2013

VI BREAST RECONSTRUCTION COURSE ON CADAVERALICANTE 4-5 OCTOBER, 2013

VI BREAST RECONSTRUCTION COURSE ON CADAVERALICANTE 4-5 OCTOBER, 2013

TRANSVERSE MYOCUTANEOUS GRACILIS (TMG/TUG) FLAP

VI BREAST RECONSTRUCTION COURSE ON CADAVERALICANTE 4-5 OCTOBER, 2013

Flap: TUG/TMG Flap

Tissues available: skin, (muscle) ___________________________________________________________________Vascular Anatomy: medial femoral circumflex artery(1.0-1.8mm) and vein(1.5-3.0mm); pedicle length 6-7cm; ___________________________________________________________________Innervation: anterior obturator nerve (motor); medial cutaneous nerve of the thigh(sensory) ___________________________________________________________________Flap Dimensions: 8x12 cm ___________________________________________________________________Advantages: expendable muscle good for additional bulk; acceptable scar location ___________________________________________________________________Disadvantages: Limited volume, especially anteriorly; small arterial diameter; seromas ___________________________________________________________________Things to note: transverse skin paddle in based in groin crease best aesthetic; avoid femoral triangle lymph nodes and stay subcutaneous to avoid lymphedema issues ___________________________________________________________________Notes:

VI BREAST RECONSTRUCTION COURSE ON CADAVERALICANTE 4-5 OCTOBER, 2013

VI BREAST RECONSTRUCTION COURSE ON CADAVERALICANTE 4-5 OCTOBER, 2013

VI BREAST RECONSTRUCTION COURSE ON CADAVERALICANTE 4-5 OCTOBER, 2013

VI BREAST RECONSTRUCTION COURSE ON CADAVERALICANTE 4-5 OCTOBER, 2013