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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_700_Библиотеки_им_академика_М_И_Перельмана
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Figure 5.
Intraoperative image of breast reconstruction showing the lateral thoracic artery perforator, base of the
fasciocutaneous flap LTAP.
Flaps for Breast Reconstruction: Different Types and Classification
It should also be mentioned that the lateral irrigation of the thorax and
upper hemiabdomen receive irrigation from the lateral thoracic artery, which
comes from the axillary artery, and delivers two to three perforators in its
lower part, creating perforators called LTAP (lateral thoracic artery perforator)
(Figure 5). These perforators supply the skin, subcutaneous tissue, and muscle
fascia at the level of the midaxillary line in the region of the sixth, seventh, and
eighth ribs.
In conclusion, the area of the chest wall beneath the inframammary fold and upper
abdominal area can be divided into four regions. Medially, the medial intercostal
artery perforator (MICAP) is present; centrally, the AICAP is present, and laterally,
the LICAP and the LTAP are present.
4. Surgical variants
The following table classifies the fasciocutaneous flaps of the upper hemiabdomen
and lower parts of the thorax. Different thoracoabdominal flaps and their surgical
variants are listed.
5. Classification
5.1 Fasciocutaneous flaps of the upper hemiabdomen and lower part of the thorax
• TYPE I: Lateral Thoracoabdominal Flaps.
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◦ I A: Anterior rotation base (based on the TLAP).
◦ I B: Posterior rotation base (based on the LICAP).
• TYPE II: Medial Thoracoabdominal Flap or Thoracoepigastric Flap (based on the
MICAP and 1st SEP).
• TYPE III: Thoracoabdominal Island Flaps.
◦ III A: Lateral rotation base (based on the LICAP).
◦ III B: Medial rotation base (based on the MICAP).
• TYPE IV: Thoracoabdominal Dermofat Flaps.
• IV A: Lateral rotation base (based on the LICAP).
• IV B: Medial rotation base (based on the MICAP).
5.1.1 TYPE I: Lateral thoracoabdominal flaps
See Figure 6.
Figure 6.
TYPE I A: Anterior rotation base (based on the TLAP). Red dot indicates the location of perforating artery.
See Figure 7.
Figure 7.
TYPE I B: Posterior rotation base (based on the LICAP). Red dot indicates the location of perforating artery.
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TYPE II: Medial thoracoabdominal flap or thoracoepigastric flap
5.1.2
Figure 8.
See
Figure 8.
TYPE II: Medial Thoracoabdominal Flap or Thoracoepigastric Flap (based on the MICAP and 1st SEP:
red dot).
Flaps for Breast Reconstruction: Different Types and Classification
5.1.3 TYPE III: Thoracoabdominal Island flaps
See Figure 9.
Figure 9.
TYPE III A: Lateral rotation base (based on the LICAP). Dotted lines indicate desepidermized area. Circular zone
indicates the skin area to be transposed.
See Figure 10.
5.1.4 TYPE IV: Thoracoabdominal dermofat flaps
See Figure 11.
See Figure 12.
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Figure 10.
TYPE III B: Medial rotation base (based on the MICAP). Dotted lines indicate desepidermized area. Circular zone
indicates the skin area to be transposed.
Figure 11.
TYPE IV A: Lateral rotation base (based on the LICAP). Dotted lines indicate desepidermized area.
Figure 12.
TYPE IV B: Medial rotation base (based on the MICAP). Dotted lines indicate desepidermized area.
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6. Fasciocutaneous
Flaps for Breast Reconstruction: Different Types and Classification
flaps of the upper abdomen and lower part of
the
thorax
Clinical cases
6.1
6.1.1
TYPE I: Lateral thoracoabdominal flaps
The lateral thoracoabdominal flap or type I is a local flap that allows elevation and
of
rotation
and
the lateral thoracic artery and the intercostal artery. It is a very versatile flap
of
allows
region
The initial description, as well as in most of the published works, uses the skin and
subcutaneous
Scarpa)
flap
The
from
according
thoracoabdominal
the skin, subcutaneous tissue, and fascia surface from the upper abdomen
lower part of the thorax. It is supplied by the perforators of the arteries tributaries
to
resolve local complications of the lower outer quadrant (LOQ) and/or medial
of
the breast [12].
tissues with the inner fascia (Superficial Fascia System — Fascia
provided from the lateral and posterior region of the thorax. In this way,
has an anterior base and rotates 90 degrees from back to front (CASE 1 and 2).
flap can also be used but with a posterior base. In this case, it provides
the anterior region of the upper abdomen (CASE 3, 4, AND 5). It is, therefore,
to
our classification, there are two variants of the lateral
flap (Figures 13–16).
pedicle
tissues
that
of
the
TYPE II: Medial thoracoabdominal flap or Thoracoepigastric flap
6.1.2
The thoracoabdominal axial flap to the medial pedicle or also frequently
“thoracoepigastric
in
lesions
perforator
tors
why
the lower inner quadrant (LIQ) of the breast. Its irrigation is given by
of
of
the superior epigastric artery.
This flap exclusively has a base of rotation directed from the epigastrium, which is
it
has no variants. It is a flap that allows the use of tissues from the
hemiabdomen
central areas and lower internal quadrants.
to
See
Figure 17.
See
Figure 18.
flap” is presented as an option for the local reconstruction
the middle thoracic artery, generally the sixth perforator, and perfora-
and contributes tissues to defects in the middle of the breast, especially
called
upper
of
the
Figure 13.
TYPE I A: I A: Anterior rotation base (based on the TLAP).
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Figure 14.
36-year-old patient with right breast reconstruction in another institution. The patient was hospitalized in our
hospital and immediately removed the expander. The TYPE I A flap was designed and applied in the area of the
surgical defect. Three months later, an anatomically shaped implant was placed, and risk-reducing mastectomy
(RRM) was performed in the left breast. Postoperative control images 1 year after the procedure.
Figure 15.
TYPE I B: Posterior rotation base (based on the LICAP).
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Flaps for Breast Reconstruction: Different Types and Classification
Figure 16.
66-year-old patient with left mastectomy and risk-reducing mastectomy were performed on the right breast. A
well-defined area of skin necrosis in the right breast was observed after 10 days. No signs of infection. A TYPE IB
thoracoabdominal flap was planned, preserving the implant placed in the first surgical procedure. Images were
taken at 6 months with reconstruction of bilateral nipple-areola complexes and solution of the skin defect.
Figure 17.
TYPE II: Medial Thoracoabdominal flap or Thoracoepigastric flap.
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Figure 18.
68-year-old patient with 10 years postoperative right mastectomy for breast carcinoma and risk-reducing
mastectomy of the left breast. She presented capsulitis with an inferior infection process and a tendency to decubitus
of the implant placed. It was decided to remove the implant, toilette the area, plan a TYPE II thoracoepigastric
flap, and place a new breast implant. Images obtained at 3 months with resolution of the problem.
6.1.3 TYPE III: Thoracoabdominal Island flaps
The thoracoabdominal island flap is described by Rose and Svensson [13] for small
defects circumscribed to the inferior-external quadrant (Variant III A) and the
inferior-internal quadrant (Variant III B). The length-to-width ratio of the flap should
not be greater than 2:1 because it is an axial flap. The defect caused by the cutaneous
island must be covered by an abdominal flap detaching to the subdermal plane.
Figure 19.
TYPE III A: Lateral rotation base (based on the LICAP).
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Flaps for Breast Reconstruction: Different Types and Classification
Figure 20.
44-year-old patient with bilateral breast reconstruction. Right breast reconstructed with a latissimus dorsi flap and
anatomical breast implant and left risk-reducing mastectomy (RRM). Circumferential necrosis is observed at
6 months in the left breast (the patient applied heat to the area). A type III A flap is placed to cover the localized
skin defect. Remote result at 6 months.
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Figure 21.
TYPE III B: Medial rotation base (based on the MICAP).
Figure 22.
40-year-old patient with breast reconstruction due to right breast cancer. An area of cutaneous distress is observed
in the right breast. Implant close to exposure. A type III B flap is placed on the medial pedicle to cover the localized
skin defect. Remote result at 6 months.
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