Sacha I. Obaid, B.A., and Donald J. Morris, M.D.
In 1937, O’Shaugnessey published in The Lancet that the greater omentum could be used to revascularize areas of schemic damage. The greater omentum gained interest as a reconstructive tool, but its use was limited because it could not reach distant locations. In 1948, the American surgeon Cannaday lengthened the omentum at the vascular pedicle and thus allowed distant sites such as the brain and the lower extremity to be reached.1 This article describes a 64-year-old woman who underwent omental flap breast reconstruction followed by a very late (> 20 years) hernia at the pedicle transposition site.
A 64-year-old woman underwent right radical mastectomy 30 years ago. She presented for reconstruction 6 years later. A silicone gel implant was used to reconstruct the pectoralis defect and another implant was used to reconstruct the breast mound. A pedicled omental flap covered both implants. The omentum was then covered with a split-thickness skin graft. On the contralateral side, a subcutaneous mastectomy and reconstruction with a Silastic implant was performed to create a more symmetric result and to satisfy the patient’s desire for bilateral mastectomy.
Twenty-four years later, this patient presented with an incisional hernia under the right costal margin that was particularly uncomfortable when standing for long periods of time. Her medical history is notable for coronary artery disease, hypertension, hypercholesterolemia, mitral valve prolapse, migraines, and diverticulitis.
At operation, the stomach and gastrocolic omentum were present in the hernia. The stomach was freed and returned to the intraperitoneal space, leaving the gastroepiploic pedicle coming through the abdominal wall defect. Despite the long period of time since transfer, there was concern that ligation of the gastroepiploic artery might lead to omental flap necrosis. The pedicle was cross-clamped and the flap was evaluated clinically and by laser Doppler perfusion imaging (Lisca Development AB, Linkoping, Sweden) to assess its perfusion. The skin graft became mottled; however, it was difficult to determine whether it would remain viable if the pedicle were ligated.
When the gastroepiploic pedicle to the omentum was cross-clamped, the perfusion in the flap dropped 27 percent from its preoperative value. At the same time, the contralateral breast’s perfusion had risen 12 percent from its preoperative value. When the pedicle was unclamped, the flap’s perfusion rose by 21.9 percent above its preoperative value and rose 67 percent over its cross-clamped value. This clearly indicated that the original gastroepiploic pedicle to the omental flap was providing a substantial portion of the blood supply to the omental flap, and that transecting the pedicle during the hernia repair might place serious strain on the omentum and overlying skin. As a result, it was decided to perform the herniorrhaphy without transsection of the vascular pedicle. Repair of the incisional hernia was performed after first transposing the pedicle extraanatomically between the eleventh and twelfth ribs. The hernia was repaired by primary repair and SIS reinforcement (Cook Surgical, Bloomington, Ind.). The patient has done well postoperatively and has subsequently experienced relief of her symptoms.
The omentum is a useful reconstructive tissue because of its rich vascularity, as pointed out by the German surgeon Paunz in 1926. In addition, it has significant antimicrobial properties. Thanks to the work of Cannaday in 1948, we know that the omentum is versatile because of its ability to be exteriorized on a vascular pedicle anywhere from the brain to the lower extremity.2 Plastic surgeons armed with free-tissue transfer technology have found that the omental and epiploic vessels have external diameters suitable for anastomosis (right gastroepiploic artery, 2 to 3.5 mm; venae comitantes, 2.5 to 3.9 mm; right omental artery, 1.8 to 2.9 mm).
Omental reconstruction is not without its pitfalls, however. The most common of all the complications are hernias in the pedicled omentoplasty. Van Garderen et al. describe incisional hernia in the extraabdominal omentoplasty as “almost inevitable.” They reported that seven of 35 (20 percent) of extraabdominal pedicled omentoplasties resulted in incisional hernias that required operative correction. 3 Contant et al. in 1996 reported nine postoperative hernias out of 34 patients (26 percent) for whom the pedicled omental flap was used to reconstruct chest wall defects.
The patient was a 64-year-old woman who suffered a similar fate, an incisional hernia, some 24 years after her omentoplasty breast reconstruction. In planning her operation, there was concern as to whether it would be necessary to save the original gastroepiploic artery pedicle to the omentum. Van Garderen et al. reported ligating the vascular pedicle and closing the fascial defect in seven of their patients who suffered postoperative herniation.3All flaps did well secondary to presumed neovascularization from surrounding tissues. This patient, however, had an unusual situation in that the omentum is covered by a “parasitic” split-thickness skin graft and lies on an implant. It is unlikely that much vascular in growth had occurred.
The use of laser Doppler flowmetry is well established for measuring the skin microcirculation. 5,6 The laser Doppler technology had previously been limited by the high spatial resolution (< 1 mm) of these devices, as it has been consistently shown that there is substantial spatial variation in tissue perfusion values, even at adjacent sites.7,8 This limitation has been overcome recently by the development of scanning laser Doppler machines that sequentially scan a piece of tissue using a moving laser beam to obtain a picture of perfusion over a broad area of tissue and then present the results as a mean perfusion value.9
One limitation of the laser Doppler perfusion imager is the inability to translate the perfusion values obtained into an absolute number of milliliters per gram per minute.9 Nevertheless, relative comparisons of tissue perfusion can be made using this machine, and to do this we have reported the tissue perfusion by percent change from preoperative baseline values.
Furthermore, because the laser Doppler machine does not physically contact the patient, this design has solved the sterility issues that have plagued other laser Doppler designs in the past. Scanning laser Doppler imagers have been used to analyze axial and random pattern flaps in the maxillofacial area,10 skin blood flow in the hand after microvascular repair of the ulnar artery at the wrist,11 and even perfusion to the gastric tube during esophageal resection.12
The laser Doppler perfusion scan aided us clinically and prevented us from potentially losing the patient’s long-standing flap. It is certainly possible that the flap would have been fine with primary pedicle ligation. The scan dissuaded us from taking that risk. Future studies might include delineation of what percentage resection in perfusion will lead to tissue necrosis.
We have presented the case of a 64-year-old woman who had undergone a true Halsted radical mastectomy 30 years ago and reconstruction 24 years ago with two silicone gel prostheses, a pedicled omental flap, and skin graft, who recently presented with a ventral hernia. Given her age and medical history, it was unclear as to whether transection of the omental pedicle would be safe. After the laser Doppler imager showed that the perfusion to the omental flap increased 67 percent over the cross-clamped value when the cross-clamp was removed from the omental pedicle, it was determined that this pedicle was providing the majority of blood flow to the omental flap and consequently that transection would not be safe.
Donald J. Morris, M.D.
Beth Israel Deaconess Medical Center
330 Brookline Avenue, CC-707
Boston, Mass. 02215
1. Liebermann-Meffert, D. The greater omentum: Anatomy,
embryology and surgical applications. Surg. Clin.
North Am. 80: 275, 2000.
2. Liebermann-Meffert, D., and White, H. (Eds.). The
Greater Omentum: Anatomy, Physiology, Pathology, Surgery,
with an Historical Survey. New York: Springer, 1983. Pp.
3. Van Garderen, J. A., Wiggers, T., and van Geel, A. N.
Complications of the pedicled omentoplasty. Neth.
J. Surg. 43: 171, 1991.
4. Contant, C. M. E., van Geel, A. N., van der Holt, B., and
Wiggers, T. The pedicled omentoplasty and split
skin graft for reconstruction of large chest wall defects:
A validity study of 34 patients. Eur J. Surg. Oncol. 22:
5. Johnson, J. M., Taylor, W. F., Shepherd, A. P., and Park,
M. K. Laser-Doppler measurement of skin blood
flow: Comparison with plethysmography. J. Appl.
Physiol. 56: 798, 1984.
6. Svensson, H., and Jonsson, B. A. Laser Doppler flowmetry
during hyperaemic reactions in the skin. Int. J.
Microcirc. Clin. Exp. 7: 87, 1988.
7. Tenland, T., Salerud, E. G., Nilsson, G. E., and Oberg,
P. A. Spatial and temporal variations in human skin
blood flow. Int. J. Microcirc. Clin. Exp. 2: 81, 1983.
8. Braverman, I. M., Keh, A., and Goldminz, D. Correlation
of laser Doppler wave patterns with underlying
microvascular anatomy. J. Invest. Dermatol. 95: 283,
9. Wardell, K., Jakobsson, A., and Nilsson, G. E. Laser
Doppler perfusion imaging by dynamic light scattering.
IEEE Trans. Biomed. Eng. 40: 309, 1993.
10. Eichhorn, W., Auer, T., Voy, E. D., and Hoffmann, K.
Laser Doppler imaging of axial and random pattern
flaps in the maxillo-facial area: A preliminary report.
J. Craniomaxillofac. Surg. 22: 301, 1994.
11. Bornmyr, S., Arner, M., and Svensson, H. Laser Doppler
imaging of finger skin blood flow in patients after
microvascular repair of the ulnar artery at the wrist.
J. Hand Surg. (Br.) 19: 295, 1994.
12. Doyle, N. H., Pearce, A., Hunter, D., Owen, W. J., and
Mason, R. C. Intraoperative scanning laser Doppler
flowmetry in the assessment of gastric tube perfusion
during esophageal resection. J. Am. Coll. Surg. 188:
Ver Halen JP, Gronet E, Kienast W. “Use of dermal regeneration template for successful coverage of chronic exposed tibia with osteomyelitis.” Accepted for publication in Op J Clin Med Case Rep, Dec 17, 2015.
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Eid A, Ver Halen JP. “Promising recent regenerative medicine applications in plastic and reconstructive surgery.” Glob Surg, accepted for publication August 13, 2015.
Eid, Ver Halen JP. Comment on “Emerging Paradigms in Perioperative Management for Microsurgical Free Tissue Transfer: Review of the Literature and Evidence-Based Guidelines.” Plast Reconstr Surg. 2015 Aug;136(2):278e-279e.
Washburn L, Meacham R, Smith A, Shih K, Qin CD, Jain U, Saha S, Samant S, Ver Halen JP. “No additional morbidity associated with adding neck dissection to a thyroidectomy: A NSQIP analysis of 44,887 patients.” Ann Surg Int 2015;1(1):1-10.
Goubran S, Ver Halen JP. “Effect of neoadjuvant chemotherapy on skin-sparing mastectomy and breast reconstruction modalities in 409 patients.” Plast Aesthet Res 2015;2:17-21.
Abbassi B, Singleton A, Eid A, Samant S, Ver Halen JP. “A rare case of pediatric pharyngeal sarcoma.” Op J Clin Med Case Rep 2015;1(5):1027.
Ver Halen JP, Eid A. “A case series of virtual surgical planning in mandibular reconstruction.” J J Otolaryn. 2015, 1(2):014.
Eid A, Ver Halen JP. “Promising recent regenerative medicine patents in plastic and reconstructive surgery: Nanotechnology, structural fat grafting, bone repair and regeneration, and microvascular surgery.” Rec Pat Regen Med, accepted for publication July 3, 2015.
Eid A, Ver Halen JP. “An analysis of underweight status on 30-day outcomes after breast reconstruction.” Plast Aesthet Res [Epub ahead of print], accepted July 1, 2015.
Jain U, Somerville J, Saha S, Hackett NJ, Ver Halen JP, Antony AK, Samant S. “Oropharyngeal Contamination Predisposes to Complications after Neck Dissection: An Analysis of 9462 Patients.” Otolaryngol Head Neck Surg. 2015 Apr 27. [Epub ahead of print]
Wood J, Ver Halen J, Samant S, Florendo N. “Radiation-induced sarcoma masquerading as osteoradionecrosis: case report and literature review.” J Laryngol Otol. 2015 Mar;129(3):279-82.
Ver Halen JP, Stoikes N, Webb D, Powell B, Voeller G. “Comprehensive analysis of donor-site morbidity in abdominally based free flap reconstruction.” Plast Reconstr Surg. 2015 Jan;135(1):226e-7e.
Grant DW, Mlodinow A, Ver Halen JP, Kim JY. “Catastrophic outcomes in free tissue transfer: A six-year review of the NSQIP database.” Plast Surg Int. 2014;2014:704206.
Mlodinow AS, Khavanin N, Ver Halen JP, Rambachan A, Gutowski KA, Kim JY. “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. 2014 Nov 25:1-7.
Smith A, Peterson D, Samant S, Ver Halen JP. “Pediatric mandibular reconstruction following resection of oral squamous cell carcinoma: A case report.” Am J Otolaryngol. 2014 Nov-Dec;35(6):826-8.
Ver Halen JP, Chen A, Jeffers L, Basu CB, ASPS Young Plastic Surgeons’ Steering Committee. “Young Plastic Surgeons Forum member survey: Part II. Advocacy in plastic surgery: opinions toward the ASPS and PlastyPAC.” Plast Reconstr Surg. 2014 Aug;134(2):353-60.
Chen A, Ver Halen JP, Basu CB, Khan S, Wang H, Jeffers L, Young Plastic Surgeons Steering Committee. “Young Plastic Surgeons Forum member Survey: Part I. Investing in the future: attitudes toward the Plastic Surgery Foundation.” Plast Recontr Surg. 2014 Aug;134(2):343-50.
Kim BD, Lim S, Wood J, Samant S, Ver Halen JP, Kim JY. “Predictors of adverse events after parotidectomy: A review of 2919 cases.” Ann Otol Rhinol Laryngol. 2015 Jan;124(1):35-44.
Qin C, Vaca E, Lovecchio F, Ver Halen JP, Hansen NM, Kim JY. “Differential impact of non-insulin-dependent diabetes mellitus and insulin-dependent diabetes mellitus on breast reconstruction outcomes.” Breast Cancer Res Treat. 2014 Jul;146(2):429-38.
Khavanin N, Mlodinow A, Kim JY, Ver Halen JP, Antony AK, Samant S. “Assessing safety and outcomes in outpatient versus inpatient thyroidectomy using the NSQIP: A propensity score matched analysis of 16,370 patients.” Ann Surg Oncol. 2015 Feb;22(2):429-36.
Kim JYS, Khavanin N, Jordan SW, Ver Halen JP, Mlodinow AS, Bethke KP, Khan SA, Hansen NM, Losken A, Fine NA. “Individualized risk of surgical-site infection: An application of the Breast Reconstruction Risk Assessment Score.” Plast Reconstr Surg. 2014 Sep;134(3):351e-362e.
Soto-Miranda MA, Ver Halen JP. “Description and implementation of an ex vivo simulator kit for developing microsurgery skills.” Annals of Plastic Surgery 2014 June; 72 Suppl 2:S208-12.
Khavanin N, Mlodinow A, Kim JY, Ver Halen JP, Samant S. “Predictors of 30-day readmission after outpatient thyroidectomy: An analysis of the 2011 NSQIP data set.” Am J Otolaryngol. 2014 May-Jun;35(3):332-9.
Kim BD, Ver Halen JP, Lim S, Kim JY. “Predictors of 61 unplanned readmission cases in microvascular free tissue transfer patients: Multi-institutional analysis of 774 patients.” Microsurgery. 2015 Jan;35(1):13-20.
Ver Halen JP, Soto-Miranda MA, Hammond S, Konofaos P, Neel M, Rao B. “Lower extremity reconstruction after limb-sparing sarcoma resection of the proximal tibia in the pediatric population: Case series, with algorithm.” Journal of Plastic Surgery and Hand Surgery 2014 Aug;48(4):238-43.
Konofaos P, Kashyap A, Ver Halen J. “Biomedical approaches to improve bone healing in distraction osteogenesis: a current update and review.” Biomed Tech (Berlin) 2014 June 1; 59(3):177-83.
Saha D, Davila AA, Ver Halen JP, Jain UK, Hansen N, Bethke K, Khan SA, Jeruss J, Fine N, Kim JY. “Post-mastectomy reconstruction: a risk-stratified comparative analysis of outcomes.” The Breast 2013 December; 22(6):1072-80.
Kim BD, Ver Halen JP, Grant DW, Kim JY. “Anesthesia duration as an independent risk factor for postoperative complications in free flap surgery: a review of 1,305 surgical cases.” Journal of Reconstructive Microsurgery 2014 May; 30(4):217-26.
Kim BD, Ver Halen JP, Mlodinow AS, Kim JYS. “Intraoperative transfusion of packed red blood cells in microvascular free tissue transfer patients: Assessment of 30-day morbidity using the NSQIP dataset.” J Reconstr Microsurg. 2014 Feb;30(2):103-14.
Mioton LM, Buck DW, Rambachan A, Ver Halen J, Dumanian GA, Kim JYS. “Predictors of readmission after outpatient plastic surgery.” Plast Reconstr Surg. 2014 Jan;133(1):173-80.
Mlodinow AS, Ver Halen JP, Lim S, Nguyen KT, Gaido JA, Kim JY. “Predictors of readmission after breast reconstruction: A multi-institutional anaylsis of 5012 patients.” Ann Plast Surg. 2013 Oct;71(4):335-41.
Konofaos P, Soto-Miranda MA, Ver Halen JP, Fleming JC. “Supratrochlear and supraorbital nerves: An anatomical study and applications in the head and neck area.” Ophthal Plast Reconstr Surg. 2013 Sep-Oct;29(5):403-8.
Soto-Miranda MA, Sandoval JA, Rao B, Neel M, Krasin M, Spunt S, Jenkins JJ, Davidoff JJ, Ver Halen JP. “Surgical treatment of pediatric desmoids tumors. A 12-year, single-center experience.” Ann Surg Oncol 2013 Oct;20(11):3384-90.
Mlodinow A, Ver Halen JP, Rambachan A, Gaido J, Kim J. “Anemia is not a predictor of free flap failure: A review of NSQIP data.” Microsurgery. 2013 Sep;33(6):432-8.
Konofaos P, Hammond S, Ver Halen J, Samant S. “Reconstructive techniques in transoral robotic surgery for head and neck cancer: A North American survey.” Plast Reconstr Surg. 2013 Feb;131(2):188e-197e.
Konofaos P, Ver Halen JP. “Nerve repair by Means of Tubulization: Past, Present, Future.” J Reconstr Microsurg. 2013 Mar;29(3):149-64.
Parks J, Kath M, Gabrick K, Ver Halen JP. “Nanotechnology applications in plastic and reconstructive surgery: A review.” Plast Surg Nurs. 2012 Oct-Dec;32(4):156-64.
Konofaos P, Ver Halen J, Neel M. “A novel magnetically-activated, fully implantable device for bone transport in long bones. Description of device, and two cases.” Plast Reconstr Surg. 2012 Sep;130(3):418e-22e.
Ver Halen J. “A Prospective Cohort Study of Fibula Free Flap Donor-Site Morbidity in 157 Consecutive Patients.” Plastic and Reconstructive Surgery, 2012 June; 129(6):1007e-1008e.
Samant M, Chang EI, Petrungaro J, Ver Halen JP, Yu P, Skoracki RJ, Chang DW. “Reconstruction of massive oncologic defects following extremity amputation: a 10-year experience.” Annals of Plastic Surgery, 2012 May; 68(5):467-71.
Ver Halen J, Skoracki R, Yu P, Chang DW. “Reconstruction of massive oncologic defects with free fillet flaps.” Plastic and Reconstructive Surgery, 2010 Mar; 125(3):913-22.
Ver Halen J, Yu P. “Reconstruction of extensive groin defects with contralateral anterolateral thigh- vastus lateralis muscle flaps.” Plastic and Reconstructive Surgery, 2010 Mar; 125(3):130e-3e.
Hopper R, VerHalen J, Tepper O, Mehrara B, Detch R, Chang E, Baharestani S, Simon B, Gurtner G. “Osteoblasts stimulated with pulsed electromagnetic fields increase HUVEC proliferation via a VEGF-independent mechanism.” Bioelectromagnetics April 2009 30:189-197.
Jensen AR, Klein MB, Ver Halen JP, Wright AS, Horvath KD. “Skin Flaps and Grafts: A Primer for the National Technical Skills Curriculum Advanced Tissue Handling Module.” Journal of Surgical Education 2008 65:191-9.
Wang H, VerHalenJ, Madariaga ML, XiangS, WangS, LanP, Oldenborg P, SykesM, YangYG. “Attenuation of Phagocytosis of Xenogeneic Cells by Manipulating CD47.” Blood 2007 109:836-42.
Movassaghi K, VerHalen J, Ganchi P, Amin-Hanjani S, Mesa J, Yaremchuk MJ. “Cranioplasty with subcutaneously preserved autologous bone grafts.” Plast Reconstr Surg 2006 117:202-6.
Yang YG, Chen AM, Garrett LJ, Sergio JJ, Theodore P, Awwad M, VerHalen J, Bodine DM, Sachs DH, Sykes M. “Development and analysis of transgenic mice expressing porcine hematopoietic cytokines: A model for achieving porcine hematopoietic chimerism across an extensive xenogeneic barrier.” Xenotransplantation 2000 7:58-64.
Lazareff JA, Peacock W, Holly L, Ver Halen J, Wong A, Olmstead C. “Multiple Shunt Failures: An Analysis of Relevant Factors.” Child’s Nervous System 1998 Jun; 14(6):271-5.