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Title: Understanding anatomical perfusion and strategies to optimize vascularity in free tissue transfer for autologous breast reconstruction using the Deep Inferior Epigastric Artery Perforator (DIEP) flap
Author: Mohan, Anita
ISNI:       0000 0004 9354 0929
Awarding Body: University of Cambridge
Current Institution: University of Cambridge
Date of Award: 2020
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Breast cancer is the commonest cancer that affects women in the United Kingdom (UK). Autologous free tissue transfer using abdominal tissue remains an excellent option for breast reconstruction following mastectomy, given greater availability of tissue and lower donor site morbidity associated with muscle-sparing approaches (perforator-based). This research evaluated microvascular anatomy of Deep Inferior Epigastric Artery Perforator (DIEP) flaps, the role of linking vessels on dynamic perfusion in bilateral breast reconstruction and strategies to augment flap vascularity. For the ex-vivo anatomical studies, three and four-dimensional computed tomographic angiography (CTA) were used to evaluate patterns of the microvascular blood supply of individual perforators and corresponding perfusion patterns in the hemi-abdomen. This was combined with an in-vivo clinical study of women undergoing bilateral DIEP breast reconstruction following mastectomy, where both preoperative CTA and intra-operative Laser-Assisted Indocyanine Green Fluorescence Angiography (LA-ICGFA) were used to evaluate perforator anatomy and dynamic perfusion zones of individual perforators. Finally, an experimental in-vivo animal model was used to investigate strategies of pretreatment of perforator flaps with negative pressure wound therapy to augment vascularity of perforator flaps prior to flap harvest. The vascular territories of individual perforator within hemi-DIEP flaps demonstrated variable patterns with unique patterns of perfusion. Concepts including early capture of large calibre direct linking vessels to adjacent perforators or the superficial inferior epigastric artery (SIEA) territories, mostly found in the supra-scarpa’s and subdermal layers of the flap, played a key role in defining overall perfusion area and dynamic perfusion patterns not previously described. In conclusion, this work reported the characterization of the microvasculature within abdominal based perforator flaps to better understand the variation in dynamic perfusion. It also explored the potential role of non-invasive negative pressure treatment to augment flap perfusion that may be translated into the clinical setting.
Supervisor: Nicholson, Mich Sponsor: Royal College of Surgeons of England ; Restoration of Appearance and Function Trust (RAFT) UK
Qualification Name: Thesis (Ph.D.) Qualification Level: Doctoral
Keywords: breast reconstruction ; flap ; microsurgery ; preconditioning ; flap anatomy ; perforator flap