A layered suture, both the arms and the breasts were performed with interrupted absorbable synthetic suture #3-0 (Glyconate-Monosyn, B. Braun Surgical, S.A.) and running subcuticular absorbable synthetic suture #4-0 (Glyconate-Monosyn, B. Braun Surgical, S.A.) was used for breast skin closure. Metallic agraphes were applied to both arm’s wounds. Sterile petrolatum gauzes and cotton gauzes were used for the postoperative dressing. The total surgery time was 3 hours 40 minutes.
Immediately after surgery, the patient wore the surgical bra for the following 40 postoperative days. Arm lift compression garments with long sleeves were carefully used. The patient was discharged on the second postoperative day, after the removal of 4 drainages. After the hospital discharge, no fever or significant symptoms were detected. The patient was invited to use a medical scar gel (Same Plast, SAME, Parma, Italy) twice a day and silicone sheets (Dermatix, Hanson Medical, Kingston, Wash.) starting from the third week after surgery, for the next 4 months.
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
During the postoperative follow-up, no complications such as seroma, hematoma, and surgical wounds dehiscence were reported. Some ecchymoses and postoperative breast and arm edema resolved before the end of the first-month follow-up. The patient did not complain about pain or inability during daily movements and did not need any kinesitherapy to return to normal activities.
The 6 months check-up showed a soft and symmetric arms silhouette with a good scar quality. No skin retraction or ptosis and no recurrent batwing deformities and liponecrosis were reported. Breasts were soft, not painful, and pleasantly shaped. A mild bulging on the lateral upper quadrant of the right breast was noticed, maybe due to inadequate defatting of the skin bridge across the axilla.
To evaluate the onset of lymphedema, a comparative assessment between preoperative and postoperative outcomes was performed. After 1, 6, and 12 months, accurate measurements of the forearm girth did not detect any changes before and after surgery. Postoperative absence of induration, and thus of lymphedema, was verified.
The patient was satisfied with the final aesthetic and functional result. The absence of liponecrosis, tissue edema, and chronic breast fistulas confirmed the survival of buried adipocutaneous PAF. No lateral displacements or asymmetries of the mammary gland were reported. One year later, the surgical results were stable, and the patient was in a good clinical condition (Fig. 8).
PAF was first described as a fasciocutaneous flap, harvested from the posteromedial aspect of the arm, with a vascularity based on an unnamed but constant artery derived from brachial artery or profunda brachii artery system.8,9 Its arc of rotation reaches 180°, contributing to reshaping the lateral and medial breast.
PAF has been reported as an islanded flap for regional reconstruction around the axilla, located in proximal arm, thorax or axillary cable, and for head and neck reconstruction. The constant anatomy, the favorable donor site morbidity, and freedom of flap insetting result in lower complication rates in the treatment of hidradenitis suppurativa, scar contractures, and postradiotherapy ulcers.22–25
Therefore, we managed to make use of PAF in postbariatric breast reshape and reconstruction. The adipocutaneous PAF variant guarantees quality of the adipose tissue similar to the one obtained from inter-costal artery perforator (ICAP), lateral inter-costal artery perforator (LICAP), spiral, and thoracodorsal artery perforator (TDAP) flap and furthermore there are no significant differences in consistency between the autologous tissue augmentation supplied by PAF and the native breast tissue. The risk of lymphedema appears comparable to that of classic brachioplasty procedures.
A comparison between the alternative flaps for autologous breast augmentation is shown in Table 1. The need to treat different body districts (depending on soft tissue redundancies location, like “back roll,” “side roll,” “bat wing”) or the acceptance of a scar located on the posteromedial aspect of the arm or on the thorax could represent a possible explanation in selecting the reconstructive technique.
Based on the comparison made in Table 1, the flap choice is not affected by the tissue quality when using fasciocutaneous, adipocutaneous, or perforator flap or by the use of prosthetic implant. Conversely, the defect location of the breast (medial and/or lateral breast), the site that needs to be treated (upper and posterior lateral chest versus posteromedial arm), the location of the future scar (thorax and back versus arm), the dimension of the flap (the LICAP flap and the latissimus dorsi flap are bigger than ICAP flap or PAF), and the risk of lymphedema (mild if PAF dissection is correctly performed in healthy/not oncological patients, severe in postaxillary lymphadenectomy patients) could address the flap alternative.
We selected McKissock mastopexy technique in combination with PAF breast autoaugmentation because of the advantages provided by the tripedicled dermoglandular flap, which is characterized by a rich vascular support and poor chance of necrosis of NAC.30,37
Potentially, the PAF is exploitable for breast implant coverage in oncological patient, if axillary lymphadenectomy is not performed, and in nononcological patient, when native soft tissues are not enough to ensure adequate prosthesis coverage.
Finally, our personal technique appeared quick and safe and combined breast and arms surgery allowed authors to reduce general anesthesia, overall time, and surgery costs.
The PAF provides a valuable option in body contouring surgery, by allowing the simultaneous treatment of 2 distinct sites deformities with 1 single combined procedure, without the use of breast implants. At present, our investigation does not allow to issue any recommendations: the effectiveness of this new combined procedure still to be validated with other cases. However, the satisfying result encouraged our team to apply this procedure to other patients.
PATIENT CONSENT STATEMENT
Informed consent was obtained from all individual participants included in the study. Additional informed consent was obtained from all individual participants for whom identifying information is included in this article.
1. Orpheu SC, Coltro PS, Scopel GP, et al. Collagen and elastic content of abdominal skin after surgical weight loss. Obes Surg. 2010;20:480–486.
2. Shermak MA, Chang DC, Heller J. Factors impacting thromboembolism after bariatric body contouring surgery. Plast Reconstr Surg. 2007;119:1590–1596; discussion 1597.
3. Mlodinow AS, Khavanin N, Ver Halen JP, et al. Increased anaesthesia duration increases venous thromboembolism risk in plastic surgery: a 6-year analysis of over 19,000 cases using the NSQIP dataset. J Plast Surg Hand Surg. 2015;49:191–197.
4. Leong G, Wilson J, Charlett A. Duration of operation as a risk factor for surgical site infection: comparison of English and US data. J Hosp Infect. 2006;63:255–262.
5. Caprini JA. Thrombosis risk assessment as a guide to quality patient care. Dis Mon. 2005;51:70–78.
6. Ghnnam W, Elrahawy A, Moghazy ME. The effect of body mass index on outcome of abdominoplasty operations. World J Plast Surg. 2016;5:244–251.
7. Frame J. The waterfall effect in breast augmentation. Gland Surg. 2017;6:193–202.
8. Masquelet AC, Rinaldi S. Anatomical basis of the posterior brachial skin flap. Anat Clin. 1985;7:155–160.
9. Masquelet AC, Rinaldi S, Mouchet A, et al. The posterior arm free flap. Plast Reconstr Surg. 1985;76:908–913.
10. Lamberty BG, Cormack GC. Progress in flap surgery: greater anatomical understanding and increased sophistication in application. World J Surg. 1990;14:776–785.
11. Tinhofer IE, Tzou CH, Duscher D, et al. Vascular territories of the medial upper arm-an anatomic study of the vascular basis for individualized flap design. Microsurgery. 2017;37:618–623.
12. Perignon D, Havet E, Sinna R. Perforator arteries of the medial upper arm: anatomical basis of a new flap donor site. Surg Radiol Anat. 2013;35:39–48.
13. Pender JR, Pories WJ. Epidemiology of obesity in the United States. Gastroenterol Clin North Am. 2005;34:1–7.
14. Pavan C, Marini M, De Antoni E, et al. Psychological and psychiatric traits in post-bariatric patients asking for body-contouring surgery. Aesthetic Plast Surg. 2017;41:90–97.
15. Pavan C, Azzi M, Lancerotto L, et al. Overweight/obese patients referring to plastic surgery: temperament and personality traits. Obes Surg. 2013;23:437–445.
16. Krueger JK, Rohrich RJ. Clearing the smoke: the scientific rationale for tobacco abstention with plastic surgery. Plast Reconstr Surg. 2001;108:1063–1073; discussion 1074.
17. Manassa EH, Hertl CH, Olbrisch RR. Wound healing problems in smokers and nonsmokers after 132 abdominoplasties. Plast Reconstr Surg. 2003;111:2082–2087; discussion 2088.
18. Gravante G, Araco A, Sorge R, et al. Wound infections in post-bariatric patients undergoing body contouring abdominoplasty: the role of smoking. Obes Surg. 2007;17:1325–1331.
19. Harrison B, Khansa I, Janis JE. Evidence-based strategies to reduce postoperative complications in plastic surgery. Plast Reconstr Surg. 2016;137:351–360.
20. Pascal JF, Le Louarn C. Brachioplasty. Aesthetic Plast Surg. 2005;29:423–439; discussion 430.
21. McKissock PK. Reduction mammaplasty with a vertical dermal flap. Plast Reconstr Surg. 1972;49:245–252.
22. Schmidt M, Dunst-Huemer KM, Lazzeri D, et al. The versatility of the islanded posterior arm flap for regional reconstruction around the axilla. J Plast Reconstr Aesthet Surg. 2015;68:953–959.
23. Costa MLR, Azevedo L, Zenha H, et al. The posterior arm flap—our department’s experience. Eur J Plast Surg. 2011;34:119–124.
24. Guha G, Agarwal AK, Gupta S, et al. Posterior arm flap in management of axillary contracture. Burns. 2013;39:972–977.
25. Pinto A, A.J., Santa-Comba A, Silva A, Mendes M. El colgajo braquial posterior en el tratamiento de la hidrosadenitis axilar: ¿ la mejor opción? Cir Plást Iberlatinamer. 2001;27:145–154.
26. Kwei S, Borud LJ, Lee BT. Mastopexy with autologous augmentation after massive weight loss: the intercostal artery perforator (ICAP) flap. Ann Plast Surg. 2006;57:361–365.
27. Hamdi M, Van Landuyt K, Blondeel P, et al. Autologous breast augmentation with the lateral intercostal artery perforator flap in massive weight loss patients. J Plast Reconstr Aesthet Surg
28. Hurwitz DJ, Agha-Mohammadi S. Postbariatric surgery breast reshaping: the spiral flap. Ann Plast Surg. 2006;56:481–486; discussion 486.
29. Levine JL, Soueid NE, Allen RJ. Algorithm for autologous breast reconstruction for partial mastectomy defects. Plast Reconstr Surg. 2005;116:762–767.
30. Nahabedian MY. Achieving ideal breast aesthetics with autologous reconstruction. Gland Surg. 2015;4:134–144.
31. Heitmann C, Pelzer M, Kuentscher M, et al. The extended latissimus dorsi flap revisited. Plast Reconstr Surg. 2003;111:1697–1701.
32. Hammond DC. Latissimus dorsi flap breast reconstruction. Plast Reconstr Surg. 2009;124:1055–1063.
33. Chiaramonte MF, Nahabedian MY. Bilateral breast reconstruction with the latissimus dorsi musculocutaneous flap: the importance of patient positioning. Ann Plast Surg. 2001;46:163–166.
34. Angrigiani C, Grilli D, Siebert J. Latissimus dorsi musculocutaneous flap without muscle. Plast Reconstr Surg. 1995;96:1608–1614.
35. Angrigiani C, Rancati A, Escudero E, et al. Propeller thoracodorsal artery perforator flap for breast reconstruction. Gland Surg. 2014;3:174–180.
36. Heitmann C, Guerra A, Metzinger SW, et al. The thoracodorsal artery perforator flap: anatomic basis and clinical application. Ann Plast Surg. 2003;51:23–29.
Copyright © 2019 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.
37. Hamdi M, Van Landuyt K, Monstrey S, et al. Pedicled perforator flaps in breast reconstruction: a new concept. Br J Plast Surg. 2004;57:531–539.