Complications Associated With Breast Reconstruction Using a Perforator Flap Compared With a Free TRAM Flap

Salvage of intraoperative deep inferior epigastric perforator flap venous congestion with augmentation of venous outflow: flap morbidity and review of the literature

BACKGROUND

Breast reconstruction with deep inferior epigastric perforator (DIEP) flaps has gained considerable popularity due to reduced donor-site morbidity. Previous studies have identified the superficial venous system as the dominant outflow to DIEP flaps. DIEP flap venous congestion occurs if superficial venous outflow via the deep venous system is insufficient for effective flap drainage. Although augmentation of venous outflow through a second venous anastomosis may relieve venous congestion, effects on flap morbidity remain ill defined.

METHODS

A retrospective analysis of 1616 patients who underwent 2618 DIEP flap breast reconstructions between March 2005 and January 2012 was performed. Patients with intraoperative venous congestion underwent a second venous anastomosis. Preoperative demographic data and methods used to relieve venous congestion were recorded. Incidence of flap morbidity was calculated and compared with a group of 418 controls having 639 DIEP flap breast reconstructions with no venous congestion.

RESULTS

Venous augmentation was required to relieve venous congestion in 87 (3.3%) DIEP flaps on 81 patients. The superficial inferior epigastric vein or accompanying deep inferior epigastric venae comitantes was used to augment venous outflow. Preoperative comorbidities were similar between both groups. Patients requiring a second venous anastomosis had a longer operative time and length of hospital stay. Overall, flap morbidity, delayed wound healing, fat necrosis, and flap loss were similar to controls.

CONCLUSIONS

Arterial and venous anatomies play unique roles in flap reliability. DIEP flap venous congestion must be treated expeditiously with venous augmentation to relieve venous congestion and mitigate flap morbidity.

A comparison of free autologous breast reconstruction with and without the use of laser-assisted indocyanine green angiography: a cost-effectiveness analysis

BACKGROUND

Laser-assisted indocyanine green angiography is a U.S. Food and Drug Administration-approved technology used to assess tissue viability and perfusion. Its use in plastic and reconstructive surgery to assess flap perfusion in autologous breast reconstruction is relatively new. There have been no previous studies evaluating the cost-effectiveness of this new technology compared with the current practice of clinical judgment in evaluating tissue perfusion and viability in free autologous breast reconstruction in patients who have undergone mastectomy.

METHODS

A comprehensive literature review was performed to identify the complication rate of the most common complications with and without laser-assisted indocyanine green angiography in free autologous breast reconstruction after mastectomy. These probabilities were combined with Medicare Current Procedural Terminology provider reimbursement codes (cost) and utility estimates for common complications from a survey of 10 plastic surgeons to fit into a decision model to evaluate the cost-effectiveness of laser-assisted indocyanine green angiography.

RESULTS

The decision model revealed a baseline cost difference of $773.66 and a 0.22 difference in the quality-adjusted life-years, yielding an incremental cost-utility ratio of $3516.64 per quality-adjusted life year favoring laser-assisted indocyanine green angiography. Sensitivity analysis showed that using laser-assisted indocyanine green angiography was more cost-effective when the complication rate without using laser-assisted indocyanine green angiography (clinical judgment alone) was 4 percent or higher.

CONCLUSIONS

The authors' study demonstrates that laser-assisted indocyanine green angiography is a cost-effective technology under the most stringent acceptable thresholds when used in immediate free autologous breast reconstruction.

Fat necrosis in autologous abdomen-based breast reconstruction: a systematic review

BACKGROUND

Fat necrosis is a common and potentially exasperating complication of autologous breast reconstruction. The authors performed a systematic review of the English literature on autologous breast reconstruction to determine significant patient and surgical factors that are predictors of postoperative fat necrosis.

METHODS

A PubMed search using the terms "fat necrosis" and "breast reconstruction" was conducted. Articles were screened using predetermined inclusion and exclusion criteria. Data collected included patient characteristics, reconstructive techniques used, and the specific postoperative morbidity of interest. Patient cohorts were pooled, and the incidence of fat necrosis was calculated in the presence and absence of each risk factor. Chi-square analysis was applied, and p < 0.05 was considered statistically significant.

RESULTS

Of 172 articles found, 70 met the inclusion criteria. The mean rate of fat necrosis was 11.3 percent. Deep inferior epigastric artery perforator flaps had the highest rate of fat necrosis (14.4 percent), followed by pedicled transverse rectus abdominis musculocutaneous (12.3 percent), superficial inferior epigastric artery (8.1 percent), and free transverse rectus abdominis musculocutaneous flaps (6.9 percent). Significant predictors of fat necrosis included obesity (p = 0.035), prereconstruction irradiation (p = 0.022), postreconstruction irradiation (p < 0.001), active smoking (p < 0.001), and abdominal scars (p = 0.05). Protective factors included supercharging (p < 0.001) and bilateral reconstruction (p = 0.01).

CONCLUSIONS

Although there is little agreement in the literature regarding risk factors for fat necrosis, the authors were able to demonstrate several significant predictors by systematically analyzing 70 articles. Improved knowledge of the risk factors for fat necrosis can help surgeons provide improved preoperative counseling and take measures to minimize the risk of this complication.

Comprehensive outcome and cost analysis of free tissue transfer for breast reconstruction: an experience with 1303 flaps

BACKGROUND

Free tissue transfer is standard for postoncologic reconstruction, yet it entails a lengthy operation and significant recovery. The authors present their longitudinal experience of free tissue breast reconstructions with an emphasis on predictors of major surgical and medical complications.

METHODS

The authors reviewed their prospectively maintained free flap database and identified oncologic breast reconstruction patients from 2005 to 2011. Factors associated with surgical and medical complications were identified using univariate analyses and logistic regression to determine predictors of complications.

RESULTS

Complications included major immediate surgical complications [n = 34 (4.0 percent)], major delayed surgical complications [n = 54 (6.4 percent)], minor surgical complications [n = 404 (47.6 percent)], and medical complications [n = 50 (5.9 percent)]. Obesity (p = 0.034), smoking (p = 0.06), flap type (p = 0.005), and recipient vessels (p < 0.001) were associated with immediate complications. Similarly, delayed surgical complications were associated with obesity (p < 0.001), chronic obstructive pulmonary disease (p < 0.001), hypertension (p < 0.001), and prior radiation therapy (p = 0.06). Regression analysis demonstrated that flap choice (p = 0.024) was independently associated with major immediate complications, and patient comorbidities such as chronic obstructive pulmonary disease (p = 0.001) and obesity (p < 0.0001) were associated with delayed complications. Patients who developed an immediate surgical complication experienced longer hospital stays (p < 0.0001), higher operating costs (p < 0.001), and greater hospital costs (p < 0.001).

CONCLUSIONS

Early major complications are related to flap selection, whereas late major complications are associated with patient comorbidities. Overall, major surgical and medical complications are associated with increased hospital length of stay and greater cost in autologous breast reconstruction.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

DIEP flap donor site versus elective abdominoplasty short-term complication rates: a meta-analysis

BACKGROUND

Although over the past decade the DIEP flap has emerged as one of the preferred choices for autologous breast reconstruction and the donor-site closure has much in common with the standard abdominoplasty technique, reports on comparisons of the complication rates between DIEP and elective abdominoplasty patients are not currently available. The purpose of this study was to compare DIEP donor-site and elective abdominoplasty short-term complications rates, in support of surgical choices.

METHODS

Searches of MEDLINE and CENTRAL for English language articles on DIEP and elective abdominoplasty (EA) published from January 1999 through December 2009 identified 33 studies that met the inclusion criteria and included 3,937 patients. A random-effects model was used to calculate the average complication rate in the literature.

RESULTS

The rate of seroma/hematoma in EA (16.1%, 95% confidence interval [CI] = 12.2-20.9%) was approximately four times the rate in DIEP flap patients (3.7%, 95% CI = 1.5-8.8%) was found from analyzing the data under a random-effects model. No substantial differences in the rates of infection, abdominal/umbilical necrosis, or wound dehiscence/delayed healing between the two series of patients were detected.

CONCLUSIONS

This meta-analysis reveals that DIEP donor-site complication rates were comparable to those in elective abdominoplasty, and, the rate of seroma in DIEP is an even lower than that of one of the most performed procedures in plastic surgery. We argue that patients presenting for a DIEP flap should be informed about this interesting comparison.

Assessment of advanced age as a risk factor in microvascular breast reconstruction

BACKGROUND

The population of elderly people is the fastest growing population in the United States. Because breast cancer typically affects the elderly population, surgeons will be performing more mastectomies in older patients. In this study, we evaluate the risks of microvascular breast reconstruction as a function of increasing age.

METHODS

Between July 2002 and September 2009, a retrospective analysis of 818 free-flap breast reconstructions was used to assess the risk of age on surgical outcomes. Patient comorbidities, the American Society of Anesthesiologists (ASA) classification, and length of hospital stay were used to assess the rates of complications among our age cohorts.

RESULTS

Advanced age was not associated with increased complications (P > 0.69). ASA class was a significant predictor of overall complications (P < 0.03) as well as the rate of fat necrosis (P < 0.01) and hematoma (P < 0.001). Flap loss occurred in 1.5% of operations, but there was no difference among the various age groups. Previous surgery was associated with an increased risk of flap loss (P < 0.001), and hypertension also increased the risk of thrombosis (P < 0.04). There was no difference in mean length of hospital stay (4.27 days).

CONCLUSIONS

Advanced age should not be considered a risk factor for microvascular breast reconstruction. Because ASA status did predict overall surgical complications, surgeons should consider the patients' overall health status in deciding whether to operate.

Perfusion-related complications are similar for DIEP and muscle-sparing free TRAM flaps harvested on medial or lateral deep inferior epigastric Artery branch perforators for breast reconstruction

BACKGROUND

Anatomical studies suggest that the deep inferior epigastric artery (DIEA) medial branch perfuses more tissue across the midline than the lateral branch. The authors hypothesized that unilateral deep inferior epigastric perforator (DIEP) and muscle-sparing free transverse rectus abdominis musculocutaneous (TRAM) flaps based on medial branch perforators would have fewer perfusion-related complications.

METHODS

The authors evaluated consecutive DIEP or muscle-sparing TRAM free flaps definitively harvested from a single DIEA branch. Flaps were grouped by tissue volume (hemiflaps, cross-midline flaps, or total flaps). Primary outcome measures were fat necrosis and partial flap necrosis. Logistic regression was used to evaluate the association between patient and reconstruction characteristics and outcomes.

RESULTS

There were 228 patients, with 120 medial (52.6 percent) and 108 lateral (47.4 percent) branch flaps. Mean follow-up was 33.2 months. Cross-midline flaps (79.8 percent) were the most common design. Medial and lateral branch flaps had similar rates of fat necrosis (8.3 percent and 13.0 percent, respectively; p = 0.26) and partial flap necrosis (3.3 percent and 2.8 percent, respectively; p = 1.0). There was no difference in the incidence of fat necrosis between DIEP and muscle-sparing free TRAM flaps (10.2 percent and 11.3 percent, respectively; p = 0.81) or in partial necrosis (3.2 percent and 2.8 percent, respectively; p = 1.0). Medial and lateral branch flap perfusion-related complications were also similar among the flap volume classifications.

CONCLUSIONS

The authors suggest that surgeons base their decisions regarding DIEA branch harvest on the clinical assessment of perforator perfusion quality rather than relying on the theoretical benefit of medial branch perforator harvest.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Abdominal wall following free TRAM or DIEP flap reconstruction: a meta-analysis and critical review

BACKGROUND

Numerous studies compare techniques for free flap breast reconstruction techniques, with no consensus regarding differences in complication rates. This study compared the risk of fat necrosis, partial flap loss, total flap loss, abdominal bulge, laxity, or weakness, and abdominal hernia after deep inferior epigastric perforator (DIEP) and free transverse rectus abdominis myocutaneous (TRAM) flap surgery for breast reconstruction.

METHODS

A MEDLINE and manual search of English-language articles on DIEP and free TRAM flap surgery published up to April of 2007 yielded 338 citations. Two levels of screening identified 37 relevant studies. The Mantel-Haenszel fixed-effects and DerSimonian and Laird random-effects models were used to perform the meta-analysis.

RESULTS

Six studies reporting both DIEP and free TRAM flap outcomes were used to estimate pooled relative risks of complications and confidence intervals. There was a twofold increase in the risk of fat necrosis (relative risk, 1.94; 95 percent CI, 1.28 to 2.93) and flap loss (relative risk, 2.05; 95 percent CI, 1.16 to 3.61) in DIEP patients compared with free TRAM patients. There was no difference in the risk for fat necrosis when the analysis was limited to studies using muscle-sparing free TRAM flaps (relative risk, 0.91; 95 percent CI, 0.47 to 1.78). DIEP patients had one-half the risk of abdominal bulge or hernia (relative risk, 0.49; 95 percent CI, 0.28 to 0.86). Sixteen studies reporting DIEP outcomes and 23 studies reporting free TRAM outcomes were used to estimate pooled complication rates. Pooled flap-related complication rates were higher in DIEP patients, whereas donor-site morbidity was higher in free TRAM patients.

CONCLUSION

This analysis suggests that the DIEP flap reduces abdominal morbidity but increases flap-related complications compared with the free TRAM flap in breast reconstruction.

Banking a hemi-abdominal DIEP flap: a pilot report of indications, technique, and utility

We present a pilot report of "banking" the contralateral hemi-abdominal deep inferior epigastric perforator (DIEP) flap under the abdominal closure in patients undergoing unilateral autologous breast reconstruction when a hemi-abdominal flap suffices. Four patients undergoing unilateral autologous breast reconstruction with a hemi-abdominal DIEP or superficial inferior epigastric artery flap had their contralateral hemi-abdominal flap left in position, or "banked," under their abdominal closure to be used in case of failure. This novel method may be of assistance when a free microvascular hemi-abdominal flap is felt to be threatened or suspect. It provides a life-boat for the younger and experienced surgeon alike, and most importantly, for the breast cancer survivor. Economic analysis of the technique reveals that the contralateral hemi-abdominal flap should be banked more often than intuition alone would suggest.

Risk factors and blood flow in the free transverse rectus abdominis (TRAM) flap: smoking and high flap weight impair the free TRAM flap microcirculation

Mastectomy patients may have significant psychologic-related problems. Breast reconstruction provides in these cases substantial benefits in restoring body image and health-related quality of live. Autologous free tissue transfer is the treatment of choice due to excellent outcome. The purpose of this study was to elucidate the effect of the risk factors on the microcirculation and clinical outcome. In this prospective study, 21 patients with a free transverse rectus abdominis (TRAM) flap breast reconstruction were included. Patient demographics and flap characteristics were recorded. Blood flow was recorded in the central part (zone I) and the distal part (zone IV) of the flap with the laser Doppler flowmetry (LDF; Perimed). In this study, increased flap complications were seen in smokers when compared with nonsmokers (P < 0.000). LDF was higher in the older patient population (P = 0.008) in zone IV. Smoking, especially in combination with a high flap weight (HFW), revealed lower blood-flow values (P = 0.020) in zone IV. Other possible influencing risk factors such as a HFW and history of radio- and chemotherapy did not alter the microcirculation. Patients with smoking and a HFW did also show decreased blood flow but also more severe flap complications.Smoking, especially in patients with a HFW, impairs the free TRAM flap microcirculation in zone IV. In our opinion, these patients can still be included for reconstruction. However, extra care has to be taken during flap design to minimize disturbed wound healing.

A Critical Review of Perioperative Complications in 175 Free Deep Inferior Epigastric Perforator Flap Breast Reconstructions

BACKGROUND

The purpose of this study was to critically evaluate the perioperative complications for deep inferior epigastric perforator (DIEP) flap breast reconstruction.

METHODS

From February 2002 until February 2006, 175 consecutive abdominal free tissue breast reconstructions were performed in 131 patients. Perioperative risk factors and complications were evaluated for the entire group. Data analysis was performed to compare subsequent chronologic groups for a learning curve effect.

RESULTS

In 159 cases (90.9%) a DIEP flap could be raised. In 13 cases (7.4%), a mini-TRAM flap and in 3 cases (1.7%) a regular free TRAM flap was harvested. A learning curve was found showing a risk for flap complications in the first 30 DIEP flaps of 40% and in flaps 31 to 175 of 13.8% (P < 0.012). Microsurgical revision rate was 4% (n = 7), with a total flap failure rate of 0.6% (n = 1). Partial flap failure rate was 8.6% (n = 15), which was solved by debridement, medial advancement, and direct closure in 6.8% (n = 12) and latissimus dorsi flap transposition in 1.8% (n = 3). Multivariate analysis showed no significant influence of risk factors on development of postoperative flap complications.

CONCLUSION

DIEP flap breast reconstruction is an excellent method, with limited donor-site morbidity. A definite learning curve was reflected in a larger number of flap complications in the beginning of our series.

Breast Reconstruction with Free Flaps from the Abdominal Donor Site—TRAM, DIEAP, and SIEA Flaps

Multiple types of free flap can be elevated from the lower abdominal region for use in breast reconstruction. These include the free transverse rectus abdominis myocutaneous flap, the deep inferior epigastric artery perforator flap, and the superficial inferior epigastric artery flap. This sequence of flaps represents an evolution in the protection of the donor site. However, the decision as to which flap may be most appropriate for an individual patient is complex. This article serves to review pertinent surgical anatomy, preoperative planning, intraoperative decision making in flap elevation, and reported outcomes.