We have developed an office-based method of assessing the volume of abdominal tissue available for breast reconstruction that has proved to be accurate, reproducible, and noninvasive, yet relatively simple, quick, cost-effective, and of no inconvenience to our patients. We prospectively evaluated 30 sequential immediate deep inferior epigastric artery perforator flap breast reconstructions (25 unilateral and five bilateral).
For assessment of breast weight, we used Bostwick's graph1 to preoperatively calculate the patient's breast weight based on their cup size and chest wall circumference. We validated this by weighing the mastectomy specimen (actual breast weight).
For assessment of flap volume, standard flap markings were used and the elliptical flap was considered as two identical triangles. The area of each triangle was calculated using the standard formula: area of triangle = height × width × ½.
The following measurements were obtained: width was measured by dropping a vertical line from the umbilicus to the suprapubic region, and height was measured from this line to the apex of the triangle (Fig. 1).
To calculate the volume of the flap, the thickness of the abdominal skin and fat were measured using a metal calliper while the abdominal panniculus was grasped by the assistant (Fig. 2). Three measurements were taken and the average of these was used. This measurement was divided by 2 (as the abdominal wall is folded onto itself during the measurement) and multiplied by the area of the flap. Therefore, the final formula for calculation of the flap volume is as follows: calculated flap volume = (height × width × ½) × 2 × (flap thickness × ½).
These calculations were validated by measuring the thickness and weight of the flap (actual flap weight) once harvested. The average calculated breast weight was 585 g (range, 345 to 1560 g) and the average actual breast weight was 505 g (range, 295 to 1510 g), giving an average percentage error of 16 percent.
The average calculated flap volume was 1306.6 ml (range, 468 to 2758.5 ml) and the average actual flap volume was 1371 g (range, 480 to 2880 g), giving an average percentage error of 4.74 percent. The average flap thickness as measured with calipers was 3.15 cm (range, 2 to 4.7 cm) and the average flap thickness measured perioperatively was 3.85 cm (range, 2.5 to 5.4 cm).
We have developed a reliable method for the preoperative assessment of flap volume using simple mathematical principles that has proved to be an invaluable tool during our first consultation, both in managing patient expectations and in constructing an operative plan. It has been particularly useful (1) to confidently inform patients of the size of the reconstructed breast; (2) in bilateral reconstructions, to assess whether a sufficient volume of flap is available; and (3) to determine whether a contralateral reduction will be required. In these highly litigious times, such a comprehensive consultation is vital for the purposes of both informed consent and ensuring that the patient's expectations mirror our own.
In addition, perioperative decisions can be facilitated.1 If a hemiflap provides sufficient volume, the superficial inferior epigastric artery pedicle can be used.2,3 In the case of large-volume (>1000 ml) breast reconstructions, the consideration of whether to raise a free transverse rectus abdominis musculocutaneous or a deep inferior epigastric artery perforator flap and in the latter how many perforators are required can be facilitated.4
We have described a validated method of calculating the abdominal flap volume available to patients undergoing autologous breast reconstruction. This technique is simple, consistently reliable, and cost effective, and has allowed us to refine our practice.
Pari-Naz Mohanna, F.R.C.S.(Plast.)
Jian Farhadi, F.M.H.
GKT Cancer Reconstruction Service, St. Thomas' Hospital, London, United Kingdom
The authors have no financial interest to declare in relation to the content of this article.
1. Bostwick J III. Available tissue reconstruction. In: Plastic and Reconstructive Breast Surgery. Vol. II. St. Louis: Quality Medical; 1990:593.
2. Spiegel AJ, Khan FN. An intraoperative algorithm for use of the SIEA flap for breast reconstruction. Plast Reconstr Surg. 2007;120:1450–1459.
3. Holm C, Mayr M, Höfter E, Ninkovic M. The versatility of the SIEA flap: A clinical assessment of the vascular territory of the superficial epigastric inferior artery. Plast Reconstr Aesthet Surg. 2007;60:946–951.
4. Nahabedian MY, Moment B, Galdino G, Manson PN. Breast reconstruction with the free TRAM or DIEP flap: Patient selection, choice of flap, and outcome. Plast Reconstr Surg. 2002;110:466–475; discussion 476–477.
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