Diametric Comparison between the Thoracodorsal Vessel and Deep Inferior Epigastric Vessel in Breast Reconstruction

Background. In microvascular anastomosis, size discrepancy is common and can increase thrombotic complications. If size differences can be predicted, then vessels of the appropriate size can be selected. This study documented the difference in diameter between the thoracodorsal (TD) vessel and deep inferior epigastric perforator (DIEP) pedicle in each patient who underwent breast reconstruction using free tissue transfer. Patients and Methods. This retrospective study included 32 anastomoses (27 breasts including five cases of supercharged anastomosis) of breast reconstruction with the free DIEP flap and TD recipient between August 2018 and June 2019. In the microscopic view, the caliber of the TD vessel, the largest branch to the serratus anterior muscle, the descending branch, the largest and the second largest branches to the latissimus dorsi muscle, and the DIEP pedicle were measured. Results. The diameter of the deep inferior epigastric artery was similar to that of the descending branch, and their anastomosing rate was 56.3%. The diameter of the deep inferior epigastric vein was similar to the branch to the serratus anterior muscle and the descending branch, and their anastomosing rates were 29.3% and 29.3%, respectively. All flaps were survived; however, in one case, a reoperation was needed to remove the hematoma, in which case fat necrosis occurred as the only complication. Conclusion. TD branches of similar size to the DIEP pedicle were prioritized in anastomosis. The descending branch and the branch to the serratus anterior muscle are expected to be good candidates as recipients in breast reconstruction with DIEP free flap. Moreover, supercharged anastomosis of DIEP pedicles can be achieved within TD branches.

Spontaneous rectus sheath hematoma– cause of acute abdomen in patients on anticoagulant therapy: two case reports

(Spontaneus) Rectus sheath hematoma ((S)RSH) is an accumulation of blood in the sheath of the rectus abdominis muscle, secondary to rupture of an epigastric vessel or muscle tear. It is defined as spontaneous in patients without history of abdominal trauma. It can be located supra- or infraumbilically. Although the exact incidence is unknown, Klingler et al. observed 23 cases (1.8%) of rectus sheath hematoma among 1257 patients evaluated by ultrasound for acute abdominal disorders. Ultrasonography can help in the diagnosis, but CT scan is most accurate in its ability to define the lesion. When diagnosed clinically, a conservative therapeutic program can usually be instituted. Only in cases of supportive management failure, progressive and large hematoma or uncontrollable hemodynamic patients, interventional management including surgery or less invasive newer techniques is indicated. Case presentation: We present two cases of SRSH in patients using oral anticoagulant agent (acenocoumarol). Their chief complaint was sudden onset of acute abdominal pain. On admission they were haemodynamically stable. After thorough clinical evaluation a suspicion for SRSH diagnosis was made and then confirmed by ultrasonography and CT. Both of them were successfully treated conservatively and discharged home in a good general condition. Conclusion: These two cases illustrate the accurate diagnosis of SRSH treated conservatively leading to optimal patient outcomes.

Proper Choice of Vessels for Supermicrosurgery Training: An Experimental Animal study

Background Reconstruction using supermicrosurgery, a technique of microneurovascular anastomosis for smaller vessels (< 0.8 mm), has become popular. Experimental animal studies for supermicrosurgery training have been reported; however, there have been few studies performed according to vessel diameter and pedicle length. In this study, the external diameters of four vessels (femoral, superficial epigastric, axillary, and common thoracic) and pedicle length of two flaps (superficial epigastric and common thoracic–long thoracic) were measured. Methods The inguinal and pectoral regions of Sprague-Dawley rats (n = 19) were dissected anatomically, and the external diameters of the four vessels were measured (right and left, artery and vein measured separately). After elevating the superficial epigastric and common thoracic–long thoracic flaps, the pedicle length of the flaps was also measured. Results Among the 16 vessels examined, the external diameters of 11 and 5 vessels were above and below 0.8 mm, respectively. The external diameters of the superficial epigastric vessel and common thoracic vessel (both arteries and veins) were below 0.8 mm. The external diameters of the femoral and axillary vessels (veins) were above 0.8 mm. The length of the common thoracic–long thoracic pedicle was approximately10 mm longer than that of the superficial epigastric pedicle. Conclusions The external diameters of the superficial epigastric vessel and common thoracic vessel are small enough for supermicrosurgery training. The pedicle lengths of both the superficial epigastric and common thoracic–long thoracic flaps are sufficient to perform free flap experiments. Supermicrosurgical free flaps using these two vessels and a study of the physiology and pharmacology of the flaps will likely be possible in the future.