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Necker FN, Cholok DJ, Fischer MJ, Shaheen MS, Gifford K, Januszyk M, Leuze CW, Scholz M, Daniel BL, Momeni A. HoloDIEP-Faster and More Accurate Intraoperative DIEA Perforator Mapping Using a Novel Mixed Reality Tool. J Reconstr Microsurg 2024. [PMID: 39038461 DOI: 10.1055/s-0044-1788548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/24/2024]
Abstract
BACKGROUND Microsurgical breast reconstruction using abdominal tissue is a complex procedure, in part, due to variable vascular/perforator anatomy. Preoperative computed tomography angiography (CTA) has mitigated this challenge to some degree; yet it continues to pose certain challenges. The ability to map perforators with Mixed Reality has been demonstrated in case studies, but its accuracy has not been studied intraoperatively. Here, we compare the accuracy of "HoloDIEP" in identifying perforator location (vs. Doppler ultrasound) by using holographic 3D models derived from preoperative CTA. METHODS Using a custom application on HoloLens, the deep inferior epigastric artery vascular tree was traced in 15 patients who underwent microsurgical breast reconstruction. Perforator markings were compared against the 3D model in a coordinate system centered on the umbilicus. Holographic- and Doppler-identified markings were compared using a perspective-corrected photo technique against the 3D model along with measurement of duration of perforator mapping for each technique. RESULTS Vascular points in HoloDIEP skin markings were -0.97 ± 6.2 mm (perforators: -0.62 ± 6.13 mm) away from 3D-model ground-truth in radial length from the umbilicus at a true distance of 10.81 ± 6.14 mm (perforators: 11.40 ± 6.15 mm). Absolute difference in radial distance was twice as high for Doppler markings compared with Holo-markings (9.71 ± 6.16 and 4.02 ± 3.20 mm, respectively). Only in half of all cases (7/14), more than 50% of the Doppler-identified points were reasonably close (<30 mm) to 3D-model ground-truth. HoloDIEP was twice as fast as Doppler ultrasound (76.9s vs. 150.4 s per abdomen). CONCLUSION HoloDIEP allows for faster and more accurate intraoperative perforator mapping than Doppler ultrasound.
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Affiliation(s)
- Fabian N Necker
- Department of Radiology, Stanford IMMERS (Incubator for Medical Mixed and Extended Reality at Stanford), Stanford University School of Medicine, Palo Alto, California
- Digital Anatomy Lab, Faculty of Medicine, Institute of Functional and Clinical Anatomy, Friedrich-Alexander Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
- Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine, Palo Alto, California
| | - David J Cholok
- Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine, Palo Alto, California
| | - Marc J Fischer
- Department of Radiology, Stanford IMMERS (Incubator for Medical Mixed and Extended Reality at Stanford), Stanford University School of Medicine, Palo Alto, California
| | - Mohammed S Shaheen
- Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine, Palo Alto, California
| | - Kyle Gifford
- Department of Radiology, 3D and Quantitative Imaging, Stanford University School of Medicine, Stanford, California
| | - Michael Januszyk
- Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine, Palo Alto, California
| | - Christoph W Leuze
- Department of Radiology, Stanford IMMERS (Incubator for Medical Mixed and Extended Reality at Stanford), Stanford University School of Medicine, Palo Alto, California
| | - Michael Scholz
- Digital Anatomy Lab, Faculty of Medicine, Institute of Functional and Clinical Anatomy, Friedrich-Alexander Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Bruce L Daniel
- Department of Radiology, Stanford IMMERS (Incubator for Medical Mixed and Extended Reality at Stanford), Stanford University School of Medicine, Palo Alto, California
| | - Arash Momeni
- Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine, Palo Alto, California
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Matsutani H, Shiraishi T, Kita Y, Fujimoto AH, Takushima A. Effectiveness of the proximal medial branch in DIEP flaps for breast reconstruction using Hartrampf zone IV. J Plast Reconstr Aesthet Surg 2024; 96:168-174. [PMID: 39094371 DOI: 10.1016/j.bjps.2024.07.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Revised: 06/13/2024] [Accepted: 07/08/2024] [Indexed: 08/04/2024]
Abstract
BACKGROUND When performing breast reconstruction using a deep inferior epigastric artery (DIEA) perforator (DIEP) flap, including Hartrampf zone IV, the bipedicled DIEP flap has been argued to be necessary to ensure stable perfusion. However, a proximal medial branch (PMB), which is the most proximal perforator of DIEA, may make it possible to obtain adequate perfusion in a unilateral DIEP flap. This study aimed to clarify the detailed anatomical characteristics of PMB and its potential clinical applications in breast reconstruction. METHODS This retrospective study was conducted on breast reconstruction using the DIEP flap between May 2020 and July 2023. Data on PMB anatomy were collected from preoperative contrast-enhanced computed tomography angiography, and contralateral perfusion of the flap was estimated using intraoperative indocyanine green angiography. RESULTS PMB was present in approximately 85% of the cases, arising near the lateral border of the rectus abdominis, branching caudomedially in more than half of the cases, and perforating 2.3 cm laterally and 8.8 cm caudally, on average, from the umbilicus. The average perfusion area of zones II and IV significantly expanded to 96.5% and 74.2%, respectively, when PMB was included in the DIEP flap, and 9 of 22 cases showed contrast extending to the entire zone IV. CONCLUSIONS The use of the DIEP flap with PMB is a good option for substantial-volume breast reconstruction. When utilizing PMB, it is important to consider its specific anatomy, location of the main perforator, and pedicle length.
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Affiliation(s)
- Hitomi Matsutani
- Department of Plastic Surgery, Kyorin University School of Medicine, 6-20-2 Shinkawa, Mitaka City, Tokyo 181-8611, Japan.
| | - Tomohiro Shiraishi
- Department of Plastic Surgery, Kyorin University School of Medicine, 6-20-2 Shinkawa, Mitaka City, Tokyo 181-8611, Japan
| | - Yukihiro Kita
- Department of Plastic Surgery, Kyorin University School of Medicine, 6-20-2 Shinkawa, Mitaka City, Tokyo 181-8611, Japan
| | - Avelino Hiroshi Fujimoto
- Department of Plastic Surgery, Kyorin University School of Medicine, 6-20-2 Shinkawa, Mitaka City, Tokyo 181-8611, Japan
| | - Akihiko Takushima
- Department of Plastic Surgery, Kyorin University School of Medicine, 6-20-2 Shinkawa, Mitaka City, Tokyo 181-8611, Japan
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Mayer HF, Coloccini A, Viñas JF. Three-Dimensional Printing in Breast Reconstruction: Current and Promising Applications. J Clin Med 2024; 13:3278. [PMID: 38892989 PMCID: PMC11172985 DOI: 10.3390/jcm13113278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2024] [Revised: 05/23/2024] [Accepted: 05/25/2024] [Indexed: 06/21/2024] Open
Abstract
Three-dimensional (3D) printing is dramatically improving breast reconstruction by offering customized and precise interventions at various stages of the surgical process. In preoperative planning, 3D imaging techniques, such as computer-aided design, allow the creation of detailed breast models for surgical simulation, optimizing surgical outcomes and reducing complications. During surgery, 3D printing makes it possible to customize implants and precisely shape autologous tissue flaps with customized molds and scaffolds. This not only improves the aesthetic appearance, but also conforms to the patient's natural anatomy. In addition, 3D printed scaffolds facilitate tissue engineering, potentially favoring the development and integration of autologous adipose tissue, thus avoiding implant-related complications. Postoperatively, 3D imaging allows an accurate assessment of breast volume and symmetry, which is crucial in assessing the success of reconstruction. The technology is also a key educational tool, enhancing surgeon training through realistic anatomical models and surgical simulations. As the field evolves, the integration of 3D printing with emerging technologies such as biodegradable materials and advanced imaging promises to further refine breast reconstruction techniques and outcomes. This study aims to explore the various applications of 3D printing in breast reconstruction, addressing current challenges and future opportunities.
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Affiliation(s)
- Horacio F. Mayer
- Plastic Surgery Department, Hospital Italiano de Buenos Aires, University of Buenos Aires Medical School, Hospital Italiano de Buenos Aires University Institute (IUHIBA), Buenos Aires C1053ABH, Argentina; (A.C.); (J.F.V.)
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Necker FN, Cholok DJ, Shaheen MS, Fischer MJ, Gifford K, Le Castillo C, Scholz M, Leuze CW, Daniel BL, Momeni A. Suture Packaging as a Marker for Intraoperative Image Alignment in Augmented Reality on Mobile Devices. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2024; 12:e5933. [PMID: 38919516 PMCID: PMC11199004 DOI: 10.1097/gox.0000000000005933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Accepted: 05/14/2024] [Indexed: 06/27/2024]
Abstract
Preoperative vascular imaging has become standard practice in the planning of microsurgical breast reconstruction. Currently, translating perforator locations from radiological findings to a patient's abdomen is often not easy or intuitive. Techniques using three-dimensional printing or patient-specific guides have been introduced to superimpose anatomy onto the abdomen for reference. Augmented and mixed reality is currently actively investigated for perforator mapping by superimposing virtual models directly onto the patient. Most techniques have found only limited adoption due to complexity and price. Additionally, a critical step is aligning virtual models to patients. We propose repurposing suture packaging as an image tracking marker. Tracking markers allow quick and easy alignment of virtual models to the individual patient's anatomy. Current techniques are often complicated or expensive and limit intraoperative use of augmented reality models. Suture packs are sterile, readily available, and can be used to align abdominal models on the patients. Using an iPad, the augmented reality models automatically align in the correct position by using a suture pack as a tracking marker. Given the ubiquity of iPads, the combination of these devices with readily available suture packs will predictably lower the barrier to entry and utilization of this technology. Here, our workflow is presented along with its intraoperative utilization. Additionally, we investigated the accuracy of this technology.
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Affiliation(s)
- Fabian N. Necker
- From the Department of Radiology, Stanford IMMERS (Incubator for Medical Mixed and Extended Reality at Stanford), Stanford University School of Medicine, Palo Alto, Calif
- Institute of Functional and Clinical Anatomy, Digital Anatomy Lab, Faculty of Medicine, Friedrich-Alexander Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine, Palo Alto, Calif
| | - David J. Cholok
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine, Palo Alto, Calif
| | - Mohammed S. Shaheen
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine, Palo Alto, Calif
| | - Marc J. Fischer
- From the Department of Radiology, Stanford IMMERS (Incubator for Medical Mixed and Extended Reality at Stanford), Stanford University School of Medicine, Palo Alto, Calif
| | - Kyle Gifford
- Department of Radiology, 3D and Quantitative Imaging, Stanford University School of Medicine, Stanford, Calif
| | - Chris Le Castillo
- Department of Radiology, 3D and Quantitative Imaging, Stanford University School of Medicine, Stanford, Calif
| | - Michael Scholz
- Institute of Functional and Clinical Anatomy, Digital Anatomy Lab, Faculty of Medicine, Friedrich-Alexander Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Christoph W. Leuze
- From the Department of Radiology, Stanford IMMERS (Incubator for Medical Mixed and Extended Reality at Stanford), Stanford University School of Medicine, Palo Alto, Calif
| | - Bruce L. Daniel
- From the Department of Radiology, Stanford IMMERS (Incubator for Medical Mixed and Extended Reality at Stanford), Stanford University School of Medicine, Palo Alto, Calif
| | - Arash Momeni
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine, Palo Alto, Calif
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Chen J, Varagur K, Xun H, Wallam S, Karius A, Ospino R, Ji J, Sanka SA, Daines J, Skladman R, Aliu O, Sacks JM. Predictors and Consequences of Intraoperative Anastomotic Failure in DIEP Flaps. J Reconstr Microsurg 2023; 39:549-558. [PMID: 36564049 DOI: 10.1055/a-2003-7890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Successful intraoperative microvascular anastomoses are essential for deep inferior epigastric perforator (DIEP) flap survival. This study identifies factors associated with anastomotic failure during DIEP flap reconstruction and analyzes the impact of these anastomotic failures on postoperative patient outcomes and surgical costs. METHODS A retrospective cohort study was conducted of patients undergoing DIEP flap reconstruction at two high-volume tertiary care centers from January 2017 to December 2020. Patient demographics, intraoperative management, anastomotic technique, and postoperative outcomes were collected. Data were analyzed using Student's t-tests, Chi-square analysis, and multivariate logistic regression. RESULTS Of the 270 patients included in our study (mean age 52, majority Caucasian [74.5%]), intraoperative anastomotic failure occurred in 26 (9.6%) patients. Increased number of circulating nurses increased risk of anastomotic failure (odds ratio [OR] 1.02, 95% confidence Interval [CI] 1.00-1.03, p <0.05). Presence of a junior resident also increased risk of anastomotic failure (OR 2.42, 95% CI 1.01-6.34, p <0.05). Increased surgeon years in practice was associated with decreased failures (OR 0.12, CI 0.02-0.60, p <0.05). Intraoperative anastomotic failure increased the odds of postoperative hematoma (OR 8.85, CI 1.35-59.1, p <0.05) and was associated with longer operating room times (bilateral DIEP: 2.25 hours longer, p <0.05), longer hospital stays (2.2 days longer, p <0.05), and higher total operating room cost ($28,529.50 vs. $37,272.80, p <0.05). CONCLUSION Intraoperative anastomotic failures during DIEP flap reconstruction are associated with longer, more expensive cases and increased rates of postoperative complications. Presence of increased numbers of circulators and junior residents was associated with increased risk of anastomotic failure. Future research is necessary to develop practice guidelines for optimizing patient and surgical factors for intraoperative anastomotic success.
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Affiliation(s)
- Jonlin Chen
- Department of Plastic and Reconstructive Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Kaamya Varagur
- Division of Plastic and Reconstructive Surgery, Washington University School of Medicine in St. Louis. St. Louis, Missouri
| | - Helen Xun
- Department of Plastic and Reconstructive Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Sara Wallam
- Department of Plastic and Reconstructive Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Alexander Karius
- Department of Plastic and Reconstructive Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Rafael Ospino
- Department of Plastic and Reconstructive Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Jenny Ji
- Division of Plastic and Reconstructive Surgery, Washington University School of Medicine in St. Louis. St. Louis, Missouri
| | - Sai Anusha Sanka
- Division of Plastic and Reconstructive Surgery, Washington University School of Medicine in St. Louis. St. Louis, Missouri
| | - John Daines
- Division of Plastic and Reconstructive Surgery, Washington University School of Medicine in St. Louis. St. Louis, Missouri
| | - Rachel Skladman
- Division of Plastic and Reconstructive Surgery, Washington University School of Medicine in St. Louis. St. Louis, Missouri
| | - Oluseyi Aliu
- Department of Plastic and Reconstructive Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Justin M Sacks
- Division of Plastic and Reconstructive Surgery, Washington University School of Medicine in St. Louis. St. Louis, Missouri
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Shammas RL, Sisk GC, Coroneos CJ, Offodile AC, Largo RD, Momeni A, Berlin NL, Hanson SE, Momoh AO, Nelson JA, Matros E, Rezak K, Phillips BT. Textbook outcomes in DIEP flap breast reconstruction: a Delphi study to establish consensus. Breast Cancer Res Treat 2023; 197:559-568. [PMID: 36441271 PMCID: PMC9892240 DOI: 10.1007/s10549-022-06820-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Accepted: 11/16/2022] [Indexed: 11/29/2022]
Abstract
PURPOSE Composite measures, like textbook outcomes, may be superior to individual metrics when assessing hospital performance and quality of care. This study utilized a Delphi process to define a textbook outcome in DIEP flap breast reconstruction. METHODS A two-round Delphi survey defined: (1) A textbook outcome, (2) Exclusion criteria for a study population, and (3) Respondent opinion regarding textbook outcomes. An a priori threshold of ≥ 70% agreement among respondents established consensus among the tested statements. RESULTS Out of 85 invitees, 48 responded in the first round and 41 in the second. A textbook outcome was defined as one that meets the following within 90 days: (1) No intraoperative complications, (2) Operative duration ≤ 12 h for bilateral and ≤ 10 h for unilateral/stacked reconstruction, (3) No post-surgical complications requiring re-operation, (4) No surgical site infection requiring IV antibiotics, (5) No readmission, (6) No mortality, (7) No systemic complications, and (8) Length of stay < 5 days. Exclusion criteria for medical and surgical characteristics (e.g., BMI > 40, HgbA1c > 7) and case-volume cut-offs for providers (≥ 21) and institutions (≥ 44) were defined. Most agreed that textbook outcomes should be defined for complex plastic surgery procedures (75%) and utilized to gauge hospital performance for microsurgical breast reconstruction (77%). CONCLUSION This Delphi study identified (1) Key elements of a textbook outcome for DIEP flap breast reconstruction, (2) Exclusion criteria for future studies, and (3) Characterized surgeon opinions regarding the utility of textbook outcomes in serving as quality metric for breast reconstruction care.
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Affiliation(s)
- Ronnie L Shammas
- Division of Plastic, Maxillofacial, and Oral Surgery, Duke University, Durham, NC, USA
| | - Geoffroy C Sisk
- Division of Plastic, Maxillofacial, and Oral Surgery, Duke University, Durham, NC, USA
| | | | - Anaeze C Offodile
- Department of Plastic and Reconstructive Surgery, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Rene D Largo
- Department of Plastic and Reconstructive Surgery, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Arash Momeni
- Division of Plastic and Reconstructive Surgery, Stanford University Medical Center, Palo Alto, Ca, USA
| | - Nicholas L Berlin
- Department of Surgery, Section of Plastic Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Summer E Hanson
- Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, IL, USA
| | - Adeyiza O Momoh
- Department of Surgery, Section of Plastic Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Jonas A Nelson
- Department of Surgery, Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Evan Matros
- Department of Surgery, Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Kristen Rezak
- Division of Plastic, Maxillofacial, and Oral Surgery, Duke University, Durham, NC, USA
| | - Brett T Phillips
- Division of Plastic, Maxillofacial, and Oral Surgery, Duke University, Durham, NC, USA.
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