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Geeroms M, Lu YJ, Hsu CC, Huang RW, Lin CH, Lin CH. Perfusion Dynamics during Secondary Flap Debulking with Liposuction. J Reconstr Microsurg 2024; 40:423-434. [PMID: 38092022 DOI: 10.1055/s-0043-1777325] [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: 06/06/2024]
Abstract
BACKGROUND Lower extremity trauma often necessitates reconstruction with flap transfer. One of the reconstructive goals is a thin soft tissue coverage with appropriate contour. Therefore, a secondary debulking of the flap is usually performed. METHODS Debulking through conventional lipectomy is compared with liposuction followed by excision of the defatted flap excess. Demographic data, surgical details, and postoperative outcomes are compared and analyzed. The perfusion dynamics of the flaps undergoing liposuction debulking are studied by means of perioperative indocyanine green fluorescence angiography, as well as postoperative laser Doppler imaging. RESULTS Patients undergoing lipectomy (n = 69; 57.5%) or liposuction (n = 51; 42.5%) debulking had a similar rate of postoperative complications. Partial necrosis was observed in 7.2% (lipectomy) versus 7.8% (liposuction) of flaps. Fluorescence angiography showed a substantial decrease in flap perfusion following the infiltration with an epinephrine-containing tumescent solution (74.3% ± 8.2% prior to infiltration versus 16.8% ± 7.1% after infiltration; p < 0.001), resulting in a dark flap appearance. Laser Doppler imaging confirmed the hypoperfusion on postoperative day 1. CONCLUSION Secondary debulking of a lower extremity flap can be safely and efficiently performed through liposuction combined with peripheral excision of the defatted flap in a single stage. Perfusion studies may show a misleading hypoperfusion of the defatted flap, which does not accurately predict subsequent necrosis or complications.
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Affiliation(s)
- Maxim Geeroms
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung Medical College and Chang Gung University, Taoyuan, Taiwan
| | - Yun-Jui Lu
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung Medical College and Chang Gung University, Taoyuan, Taiwan
| | - Chung-Chen Hsu
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung Medical College and Chang Gung University, Taoyuan, Taiwan
| | - Ren-Wen Huang
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung Medical College and Chang Gung University, Taoyuan, Taiwan
| | - Chih-Hung Lin
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung Medical College and Chang Gung University, Taoyuan, Taiwan
| | - Cheng-Hung Lin
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung Medical College and Chang Gung University, Taoyuan, Taiwan
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Promny T, Huberth P, Müller-Seubert W, Promny D, Cai A, Horch RE, Arkudas A. The Impact of Technical Innovations and Donor-Site Mesh Repair on Autologous Abdominal-Based Breast Reconstruction-A Retrospective Analysis. J Clin Med 2024; 13:2165. [PMID: 38673438 PMCID: PMC11050223 DOI: 10.3390/jcm13082165] [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: 02/13/2024] [Revised: 04/06/2024] [Accepted: 04/08/2024] [Indexed: 04/28/2024] Open
Abstract
Background: The aim of this study was to examine the potential benefit that may be achieved through the introduction of technical innovations and the incorporation of mesh for fascial donor site closure in uni- and bilateral autologous breast reconstruction with abdominal tissue. Methods: A retrospective single-center review of all breast reconstructions with a DIEP or MS-TRAM flap between January 2004 and December 2019 was performed. Donor and recipient site complications and operation times were evaluated before and after the implementation of coupler anastomoses, preoperative computed tomography angiography (CTA), indocyanine green (ICG) angiography, and the inclusion of mesh in donor site repair. Results: A total of 396 patients were included, accounting for 447 flaps. Operation time was significantly shorter in unilateral reconstructions after the implementation of CTA (p < 0.0001). ICG angiography significantly reduced the rates of partial flap loss (p = 0.02) and wound healing disorders (p = 0.02). For unilateral reconstructions, abdominal bulging or hernia was observed more often in MS1-TRAM flaps without synthetic mesh repair (p = 0.001), whereas conservatively treated seroma developed more frequently after mesh implantation (p = 0.03). Conclusions: Recent technological advancements developed over the past few decades have made a substantial impact on decreasing surgical duration and enhancing procedure safety.
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Affiliation(s)
- Theresa Promny
- Department of Plastic and Hand Surgery and Laboratory for Tissue Engineering and Regenerative Medicine, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nürnberg (FAU), 91054 Erlangen, Germany; (P.H.); (W.M.-S.); (D.P.); (A.C.); (R.E.H.); (A.A.)
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Wang Z, Jiao L, Chen S, Li Z, Xiao Y, Du F, Huang J, Long X. Flap perfusion assessment with indocyanine green angiography in deep inferior epigastric perforator flap breast reconstruction: A systematic review and meta-analysis. Microsurgery 2023; 43:627-638. [PMID: 37165852 DOI: 10.1002/micr.31056] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 04/01/2023] [Accepted: 04/27/2023] [Indexed: 05/12/2023]
Abstract
BACKGROUND Indocyanine green angiography (ICG-A) has been widely applied for intraoperative flap assessment in DIEP flap breast reconstruction. However, the beneficial effect of ICG-A in DIEP flap breast reconstruction is still uncertain and no standardized protocol is available. This study aims to analyze the clinical outcome and comprehensively review protocols of this field. METHODS A systematic review was conducted in MEDLINE, EMBASE, and Cochrane CENTRAL databases until September 15, 2022. Studies on the utility of intraoperative ICG-A in DIEP breast reconstruction were included. Data reporting reconstruction outcomes were extracted for pooled analysis. RESULTS A total of 22 studies were enrolled in the review, among five studies with 1021 patients included in the meta-analysis. The protocols of ICG-A assessment of DIEP flap varied among studies. According to the pooled results, the incidence of postoperative fat necrosis was 10.89% (50 of 459 patients) with ICG-A and 21.53% (121 of 562 patients) with clinical judgment. The risk for postoperative fat necrosis was significantly lower in patients with intraoperative ICG-A than without (RR 0.47 95% CI 0.29-0.78, p = .004, I2 = 51%). Reoperation occurred in 5 of 48 patients (10.42%) in the ICG-A group and in 21 of 64 patients (32.82%) in the control group summarized from reports in two studies. The risk for reoperation was lower in the ICG-A group than in the control group (RR 0.41 95% CI 0.18-0.93, p = .03, I2 = 0%). Other complications, including flap loss, seroma, hematoma, dehiscence, mastectomy skin necrosis, and infection, were comparable between the two groups. Heterogeneities among studies were acceptable. No significant influence of specific studies was identified in sensitivity analysis. CONCLUSIONS ICG-A is an accurate and reliable way to identify problematic perfusion of DIEP flaps during breast reconstruction. Protocols of ICG-A differed in current studies. Intraoperative ICG-A significantly decreases the rate of fat necrosis and reoperation in patients undergoing DIEP breast reconstruction. The synthesized results should be interpreted sensibly due to the sample size limitation. RCTs on the outcomes and high-quality studies for an optimized ICG-A protocol are still needed in the future.
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Affiliation(s)
- Zhaojian Wang
- Department of Plastic and Aesthetic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, People's Republic of China
| | - Ling Jiao
- Department of Dermatology, West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | - Siliang Chen
- Department of Dermatology, West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | - Zhijin Li
- Department of Plastic and Aesthetic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, People's Republic of China
| | - Yiding Xiao
- Department of Plastic and Aesthetic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, People's Republic of China
| | - Fengzhou Du
- Department of Plastic and Aesthetic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, People's Republic of China
| | - Jiuzuo Huang
- Department of Plastic and Aesthetic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, People's Republic of China
| | - Xiao Long
- Department of Plastic and Aesthetic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, People's Republic of China
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Kim PJ, Yuan M, Wu J, Gallo L, Uhlman K, Voineskos SH, O’Neill A, Hofer SO. "Spin" in Observational Studies in Deep Inferior Epigastric Perforator Flap Breast Reconstruction: A Systematic Review. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e5095. [PMID: 37351115 PMCID: PMC10284325 DOI: 10.1097/gox.0000000000005095] [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: 01/24/2023] [Accepted: 04/26/2023] [Indexed: 06/24/2023]
Abstract
The deep inferior epigastric artery perforator (DIEP) flap is widely used in autologous breast reconstruction. However, the technique relies heavily on nonrandomized observational research, which has been found to have high risk of bias. "Spin" can be used to inappropriately present study findings to exaggerate benefits or minimize harms. The primary objective was to assess the prevalence of spin in nonrandomized observational studies on DIEP reconstruction. The secondary objectives were to determine the prevalence of each spin category and strategy. Methods MEDLINE and Embase databases were searched from January 1, 2015, to November 15, 2022. Spin was assessed in abstracts and full-texts of included studies according to criteria proposed by Lazarus et al. Results There were 77 studies included for review. The overall prevalence of spin was 87.0%. Studies used a median of two spin strategies (interquartile range: 1-3). The most common strategies identified were causal language or claims (n = 41/77, 53.2%), inadequate extrapolation to larger population, intervention, or outcome (n = 27/77, 35.1%), inadequate implication for clinical practice (n = 25/77, 32.5%), use of linguistic spin (n = 22/77, 28.6%), and no consideration of the limitations (n = 21/77, 27.3%). There were no significant associations between selected study characteristics and the presence of spin. Conclusions The prevalence of spin is high in nonrandomized observational studies on DIEP reconstruction. Causal language or claims are the most common strategy. Investigators, reviewers, and readers should familiarize themselves with spin strategies to avoid misinterpretation of research in DIEP reconstruction.
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Affiliation(s)
- Patrick J. Kim
- From the Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Morgan Yuan
- Division of Plastic, Reconstructive and Aesthetic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Jeremy Wu
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Lucas Gallo
- Division of Plastic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Kathryn Uhlman
- Division of Plastic, Reconstructive and Aesthetic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Sophocles H. Voineskos
- Division of Plastic, Reconstructive and Aesthetic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Anne O’Neill
- Division of Plastic, Reconstructive and Aesthetic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Stefan O.P. Hofer
- Division of Plastic, Reconstructive and Aesthetic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
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Choudhary S, Khanna S, Mantri R, Arora P. Role of Indocyanine Green Angiography in Free Flap Surgery: A Comparative Outcome Analysis of a Single-Center Large Series of 877 Consecutive Free Flaps. Indian J Plast Surg 2023; 56:208-217. [PMID: 37435339 PMCID: PMC10332904 DOI: 10.1055/s-0043-57270] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/13/2023] Open
Abstract
Purpose This study aims to assess and validate the role and cost-effectiveness of indocyanine green angiography (ICGA) in free flap surgery outcomes. A new intraoperative protocol of whole-body surface warming (WBSW) for all free flap surgeries during the strategic "microbreaks" is also described. Methods A retrospective analysis of 877 consecutive free flaps, performed over 12 years, is presented. The results of the ICGA group ( n = 438) were compared with the historical No-ICGA group ( n = 439), and statistical significance was calculated for three crucial flap-related adverse outcomes and cost-effectiveness. ICGA was also used as a tool to show the effect of WBSW on free flaps. Results ICGA showed a notably strong statistical significance in decreasing two outcome parameters, namely, partial flap loss and re-exploration rate. It was also cost-effective. ICGA also demonstrated the positive role of WBSW in increasing flap perfusion. Conclusions Our study shows that the usage of ICGA for intraoperative assessment of flap perfusion can significantly reduce the partial flap loss and re-exploration rate in free flap surgeries in a cost-effective manner. A new protocol of WBSW is also described and recommended to increase flap perfusion in all free flap surgeries.
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Affiliation(s)
- Sunil Choudhary
- Max Institute of Reconstructive Aesthetic Cleft and Craniofacial Surgery (MIRACLES), Max Super Specialty Hospital, Saket, New Delhi, India
| | - Soumya Khanna
- Max Institute of Reconstructive Aesthetic Cleft and Craniofacial Surgery (MIRACLES), Max Super Specialty Hospital, Saket, New Delhi, India
| | - Raghav Mantri
- Max Institute of Reconstructive Aesthetic Cleft and Craniofacial Surgery (MIRACLES), Max Super Specialty Hospital, Saket, New Delhi, India
| | - Prateek Arora
- Max Institute of Reconstructive Aesthetic Cleft and Craniofacial Surgery (MIRACLES), Max Super Specialty Hospital, Saket, New Delhi, India
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6
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Saiga M, Nakagiri R, Mukai Y, Matsumoto H, Kimata Y. Trends and issues in clinical research on satisfaction and quality of life after mastectomy and breast reconstruction: a 5-year scoping review. Int J Clin Oncol 2023:10.1007/s10147-023-02347-5. [PMID: 37160493 DOI: 10.1007/s10147-023-02347-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 04/20/2023] [Indexed: 05/11/2023]
Abstract
Breast reconstruction (BR) aims to improve the satisfaction and quality of life (QOL) of breast cancer survivors. Clinical studies using patient-reported outcomes (PROs) can therefore provide relevant information to the patients and support decision-making. This scoping review was conducted to analyze recent trends in world regions, methods used, and factors investigated. The literature search was conducted in August 2022. Databases of PubMed, MEDLINE, and CINAHL were searched for relevant English-language studies published from 2017 to 2022. Studies involving women with breast cancer who underwent BR after mastectomy and investigated PROs after BR using BR-specific scales were included. Data on the country, publication year, study design, PRO measures (PROMs) used, time points of surveys, and research themes were collected. In total, 147 articles met the inclusion criteria. BREAST-Q was the most widely used, contributing to the increase in the number and diversification of studies in this area. Such research has been conducted mainly in North America and Europe and is still developing in Asia and other regions. The research themes involved a wide range of clinical and patient factors in addition to surgery, which could be influenced by research methods, time since surgery, and even cultural differences. Recent BR-specific PROMs have led to a worldwide development of research on factors that affect satisfaction and QOL after BR. PRO after BR may be influenced by local cultural and social features, and it would be necessary to accumulate data in each region to draw clinically useful conclusion.
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Affiliation(s)
- Miho Saiga
- Department of Plastic Surgery, Okayama University Hospital, 2-5-1, Shikata-cho, Kita-ku, Okayama City, Okayama, 700-8558, Japan.
| | - Ryoko Nakagiri
- Department of Plastic Surgery, Okayama University Hospital, 2-5-1, Shikata-cho, Kita-ku, Okayama City, Okayama, 700-8558, Japan
| | - Yuko Mukai
- Department of Plastic Surgery, Okayama Rosai Hospital, Okayama, Japan
| | - Hiroshi Matsumoto
- Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Yoshihiro Kimata
- Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
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Xie J, Yan W, Zhu Z, Wang M, Shi J. Advances in Prepectoral Breast Reconstruction. Ther Clin Risk Manag 2023; 19:361-368. [PMID: 37095832 PMCID: PMC10122485 DOI: 10.2147/tcrm.s404799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Accepted: 04/01/2023] [Indexed: 04/26/2023] Open
Abstract
Breast reconstruction can be divided into prepectoral breast reconstruction (PPBR) and subpectoral breast reconstruction (SPBR) according to the implant plane. The original prepectoral breast reconstruction was abandoned for a long time due to the frequent and severe complications. Now, advances in materials technology and improved methods of mastectomy have made safe prepectoral breast reconstruction possible. Moreover, a number of studies have gradually demonstrated the advantages of prepectoral breast reconstruction. As prepectoral breast reconstruction becomes more and more attractive, it is time to review the current advances in prepectoral breast reconstruction.
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Affiliation(s)
- Jiaheng Xie
- Department of Burn and Plastic Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, People’s Republic of China
| | - Wei Yan
- Department of Burn and Plastic Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, People’s Republic of China
| | - Zhechen Zhu
- Department of Burn and Plastic Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, People’s Republic of China
| | - Ming Wang
- Department of Burn and Plastic Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, People’s Republic of China
| | - Jingping Shi
- Department of Burn and Plastic Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, People’s Republic of China
- Correspondence: Jingping Shi; Ming Wang, Department of Burn and Plastic Surgery, The First Hospital Affiliated to Nanjing Medical University, Nanjing, Jiangsu, 210029, People’s Republic of China, Tel +8613082555422, Email ;
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8
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Li S, Luo X, Zhang Z, Raza MA, Jin Z, Yao C, Yan H. Differences between novel hybrid mode flaps and traditional perforator flaps at the level of metabolites using LC-MS. Biomed Chromatogr 2022; 36:e5466. [PMID: 35902233 DOI: 10.1002/bmc.5466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 05/29/2022] [Accepted: 06/06/2022] [Indexed: 11/09/2022]
Abstract
The multi-territory perforator flaps are widely used in plastic surgery. However, partial necrosis flap in the potential territory remains a challenge to plastic surgeons. We raised a novel "hybrid nourished mode" (HNM) flap based on the multi-territory deep inferior epigastric perforator (DIEP) flap to improve flap survival. Thirty-two rabbits were randomly divided into DIEP and HNM groups. Untargeted metabolic mechanisms between the DIEP and HNM groups were performed using LC-MS under the filter criteria of fold change >20.0 times or <0.05, and variable importance in projection (VIP) value was set at ≥1, P < 0.05. Between the two groups, flap survival, perfusion, microvasculature, histopathology, and immunohistochemistry of CD31 were assessed on post-operative day 7. We screened 16 different metabolites that mainly participated in biosynthesis of secondary metabolites, aminoacyl transfer RNA biosynthesis, phenylalanine metabolism, arginine and proline metabolism, among others. The results of the HNM flaps were higher than those of the DIEP flaps (P < 0.05) in the aspects of flap survival, flap perfusion, and microvasculature. Compared with the DIEP flaps, HNM has a stronger advantage in tissue metabolism. This study provided us with a better understanding and strong evidence in terms of metabolites on how HNM achieves the survival of large multi-territory perforator flaps.
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Affiliation(s)
- Shi Li
- Department of Orthopedics (Division of Hand Surgery), The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, China
- Key Laboratory of Orthopedics of Zhejiang Province, Wenzhou, China
- The Second School of Medicine, Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Xiaobin Luo
- Department of Orthopedics (Division of Hand Surgery), The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, China
- Key Laboratory of Orthopedics of Zhejiang Province, Wenzhou, China
- The Second School of Medicine, Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Zhe Zhang
- Department of Orthopedics (Division of Hand Surgery), The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, China
- Key Laboratory of Orthopedics of Zhejiang Province, Wenzhou, China
- The Second School of Medicine, Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Mazhar Ali Raza
- Department of Orthopedics (Division of Hand Surgery), The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, China
- Key Laboratory of Orthopedics of Zhejiang Province, Wenzhou, China
- The Second School of Medicine, Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Zeyuan Jin
- Department of Orthopaedics, Jiaxing Second Hospital, Second Affiliated Hospital of Jiaxing Medical College, Jiaxing, China
| | - Chenglun Yao
- Department of Orthopedics (Division of Hand Surgery), The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, China
- Key Laboratory of Orthopedics of Zhejiang Province, Wenzhou, China
- The Second School of Medicine, Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Hede Yan
- Department of Orthopedics (Division of Hand Surgery), The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, China
- Key Laboratory of Orthopedics of Zhejiang Province, Wenzhou, China
- The Second School of Medicine, Wenzhou Medical University, Wenzhou, Zhejiang, China
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9
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Yoo A, Palines PA, Mayo JL, Bartow MJ, Danos DM, St Hilaire H, Wise MW, Stalder MW. The Impact of Indocyanine Green Angiography on Fat Necrosis in Deep Inferior Epigastric Perforator Flap Breast Reconstruction. Ann Plast Surg 2022; 88:415-419. [PMID: 34611093 DOI: 10.1097/sap.0000000000003021] [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: 11/25/2022]
Abstract
BACKGROUND The deep inferior epigastric perforator flap (DIEP) is a widely known reliable option for autologous breast reconstruction. One common complication of DIEP procedures is fat necrosis. Consequences of fat necrosis include wound healing complications, pain, infection, and the psychological distress of possible cancerous recurrence. Clinical judgment alone is an imperfect method to detect at-risk segments of adipose tissue. Objective methods to assess perfusion may improve fat necrosis complication rates, reducing additional surgeries to exclude cancer and improve cosmesis for patients. METHODS The authors performed a retrospective review of patients who underwent analysis of DIEP flap vascularity with or without intraoperative indocyanine green angiography (ICGA). Flap perfusion was assessed using intravenous ICGA and was quantified with both relative and absolute value units of fluorescence. Tissue with observed values less than 25% to 30% relative value units was resected. Postoperative outcomes and fat necrosis incidence were collected. RESULTS Three hundred fifty-five DIEP flaps were included in the study, 187 (52.7%) of which were assessed intraoperatively with ICGA. Thirty-nine patients (10.9%) experienced operable fat necrosis. No statistically significant difference in incidence of postoperative fat necrosis was found between the 2 groups (P = 0.732). However, a statistically significant relationship was found between fat necrosis incidence and body mass index as both a continuum (P = 0.001) and when categorized as greater than 35 (P = 0.038). CONCLUSIONS Although ICGA is useful for a variety of plastic surgery procedures, our retrospective review did not show a reduction in operable fat necrosis when using this technology.
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Affiliation(s)
- Aran Yoo
- From the Division of Plastic and Reconstructive Surgery
| | | | - James L Mayo
- From the Division of Plastic and Reconstructive Surgery
| | | | - Denise M Danos
- Department of Behavioral and Community Health, Louisiana State University Health Sciences Center
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Michi M, Madu M, Winters HAH, de Bruin DM, van der Vorst JR, Driessen C. Near-Infrared Fluorescence with Indocyanine Green to Assess Bone Perfusion: A Systematic Review. Life (Basel) 2022; 12:life12020154. [PMID: 35207442 PMCID: PMC8875533 DOI: 10.3390/life12020154] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 01/16/2022] [Accepted: 01/18/2022] [Indexed: 11/16/2022] Open
Abstract
Background: Adequate perfusion of a bone flap is essential for successful reconstruction of osseous defects. Unfortunately, complications related to inadequate bone perfusion are common. Near-infrared fluorescence (NIRF) imaging enables intraoperative visualization of perfusion. NIRF has been investigated in reconstructive surgery to aid the surgeon in clinical perioperative assessment of soft tissue perfusion. However, little is known on the beneficial use of NIRF to assess bone perfusion. Therefore, the aim of this review was to search for studies evaluating NIRF to assess bone perfusion. Methods: A systematic review, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline, was performed. Studies up to October 2021 were included. We extracted data regarding the study population, size and design, reported objective fluorescence parameters and the methodology used for fluorescence imaging and processing. Results: Ten articles were included. Studies reported unevenly on the protocol used for NIRF imaging. Five studies reported objective parameters. Absolute and relative perfusion parameters and parameters derived from maximum fluorescence were reported. The clinical significance of these parameters has not been evaluated in humans. Conclusion: The evidence on bone perfusion as measured with NIRF is limited. More clinical studies are required.
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Affiliation(s)
- Marlies Michi
- Department of Surgery, Alrijne Hospital, Simon Smitweg 1, 2353 GA Leiderdorp, The Netherlands
- Correspondence:
| | - Max Madu
- Department of Plastic Surgery, Amsterdam University Medical Center, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands; (M.M.); (H.A.H.W.); (C.D.)
| | - Henri A. H. Winters
- Department of Plastic Surgery, Amsterdam University Medical Center, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands; (M.M.); (H.A.H.W.); (C.D.)
| | - Daniel M. de Bruin
- Department of Biomedical Engineering and Physics, Amsterdam University Medical Center, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands;
- Department of Urology, Amsterdam University Medical Center, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Joost R. van der Vorst
- Department of Surgery, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands;
| | - Caroline Driessen
- Department of Plastic Surgery, Amsterdam University Medical Center, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands; (M.M.); (H.A.H.W.); (C.D.)
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11
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Michi M, Verduijn PS, Corion LUM, Vahrmeijer AL, Mulder BGS. Assessment of deep inferior epigastric perforator flap perfusion with near-infrared fluorescence: A pilot study and description of a standardized working protocol. J Plast Reconstr Aesthet Surg 2021; 75:1171-1178. [PMID: 34924327 DOI: 10.1016/j.bjps.2021.11.043] [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: 07/12/2020] [Revised: 05/20/2021] [Accepted: 11/08/2021] [Indexed: 11/25/2022]
Abstract
Fat necrosis (FN) is a common complication after autologous breast reconstruction (ABR) using a free flap, which can influence reconstruction outcome and patient satisfaction. Intraoperative near-infrared fluorescence imaging using indocyanine green (ICG) permits the visualization of flap perfusion. The aim of this study was to assess the effect of near-infrared fluorescence on FN incidence in patients undergoing an ABR with a deep inferior epigastric perforator flap (DIEP) and to propose a standard working protocol for this technique. In this prospective study, patients undergoing one-sided ABR with a DIEP were included. The standard DIEP procedure was complemented with near-infrared fluorescence imaging using the fluorescent tracer ICG to evaluate flap perfusion. This cohort was compared to a retrospective cohort of DIEP procedures without near-infrared fluorescence imaging. Patients and surgery characteristics, as well as postoperative complications, were registered and compared. In both cohorts, 24 patients were included. No significant differences were present between patients and surgery characteristics, including no difference in duration of surgery. In the prospective and retrospective group, the incidence of FN was 4.2% and 33%, respectively (p-value = 0.023). Moreover, microsurgeons were positive about using near-infrared fluorescence as it either provided additional information about perfusion or confirmed the clinical assessment. Our pilot study showed a significant decrease of FN in patients undergoing an ABR with a DIEP when near-infrared fluorescence imaging was used to assess flap perfusion. This study provides a standardized working protocol for near-infrared fluorescence imaging. In the future, large multicenter studies should focus on the quantification of near-infrared fluorescence imaging.
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Affiliation(s)
- Marlies Michi
- Department of Plastic Surgery, Leiden University Medical Center, P.O. Box 9600, Albinusdreef 2, 2333 ZA Leiden, the Netherlands.
| | - Pieter S Verduijn
- Department of Plastic Surgery, Leiden University Medical Center, P.O. Box 9600, Albinusdreef 2, 2333 ZA Leiden, the Netherlands
| | - Leonard U M Corion
- Department of Plastic Surgery, Leiden University Medical Center, P.O. Box 9600, Albinusdreef 2, 2333 ZA Leiden, the Netherlands
| | - Alexander L Vahrmeijer
- Department of Surgery, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, the Netherlands
| | - Babs G Sibinga Mulder
- Department of Surgery, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, the Netherlands
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Khan H, Khatib M, Griffiths M. Outcomes of DIEP Flap and Fluorescent Angiography: A Randomized Controlled Clinical Trial. Plast Reconstr Surg 2021; 147:557e-558e. [PMID: 33347085 DOI: 10.1097/prs.0000000000007648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Hasaan Khan
- Sir Alexander Fleming Building, Imperial College London, London
| | - Manaf Khatib
- St. Andrew's Centre for Plastic Surgery and Burns, Broomfield Hospital, Chelmsford, United Kingdom
| | - Matthew Griffiths
- St. Andrew's Centre for Plastic Surgery and Burns, Broomfield Hospital, Chelmsford, United Kingdom
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In Vivo Perforasome Perfusion in Hemi-DIEP Flaps Evaluated with Indocyanine-green Fluorescence Angiography and Infrared Thermography. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2021; 9:e3560. [PMID: 34036020 PMCID: PMC8140778 DOI: 10.1097/gox.0000000000003560] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Accepted: 02/22/2021] [Indexed: 12/24/2022]
Abstract
There are no in vivo studies that evaluate the effect of perforator dissection on the perfusion territory of a perforator (perforasome). In this study, indocyanine green fluorescence angiography (ICG-FA) and infrared thermography (IRT) were used intraoperatively to evaluate perforasome perfusion in hemi-DIEP flaps.
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Parmeshwar N, Sultan SM, Kim EA, Piper ML. A Systematic Review of the Utility of Indocyanine Angiography in Autologous Breast Reconstruction. Ann Plast Surg 2021; 86:601-606. [PMID: 33346549 DOI: 10.1097/sap.0000000000002576] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND In the last decade, a number of studies have demonstrated the utility of indocyanine green (ICG) angiography in predicting mastectomy skin flap necrosis for immediate breast reconstruction. However, data are limited to investigate this technique for autologous breast reconstruction. Although it may have the potential to improve free flap outcomes, there has not been a large multicenter study to date that specifically addresses this application. METHODS A thorough literature review based on Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines was conducted. All studies that examined the use of intraoperative ICG angiography or SPY to assess perfusion of abdominally based free flaps for breast reconstruction from January 1, 2000, to January 1, 2020, were included. Free flap postoperative complications including total flap loss, partial flap loss, and fat necrosis were extracted from selected studies. RESULTS Nine relevant articles were identified, which included 355 patients and 824 free flaps. A total of 472 free flaps underwent clinical assessment of perfusion intraoperatively, whereas 352 free flaps were assessed with ICG angiography. Follow-up was from 3 months to 1 year. The use of ICG angiography was associated with a statistically significant decrease in flap fat necrosis in the follow-up period (odds ratio = 0.31, P = 0.02). There was no statistically significant difference for total or partial flap loss. CONCLUSIONS From this systematic review, it can be concluded that ICG angiography may be an effective and efficient way to reduce fat necrosis in free flap breast reconstruction and may be a more sensitive predictor of flap perfusion than clinical assessment alone. Future prospective studies are required to further determine whether ICG angiography may be superior to clinical assessment in predicting free flap outcomes.
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Affiliation(s)
- Nisha Parmeshwar
- From the Division of Plastic Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Steven M Sultan
- Division of Plastic Surgery, Department of Surgery, Ucahn School of Medicine at Mount Sinai
| | - Esther A Kim
- From the Division of Plastic Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Merisa L Piper
- From the Division of Plastic Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA
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15
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Lauritzen E, Damsgaard TE. Use of Indocyanine Green Angiography decreases the risk of complications in autologous- and implant-based breast reconstruction: A systematic review and meta-analysis. J Plast Reconstr Aesthet Surg 2021; 74:1703-1717. [PMID: 33931326 DOI: 10.1016/j.bjps.2021.03.034] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 03/08/2021] [Accepted: 03/13/2021] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Indocyanine Green Angiography (ICG-A) is an imaging technique used to visualize tissue perfusion in real time. The aim of this systematic review and meta-analysis is to evaluate all published papers on breast reconstruction using ICG-A, which provides information on complication rates and to investigate whether the use of this peroperative method decreases the risk of complications. MATERIALS AND METHODS MEDLINE/PubMed, EMBASE, Cochrane, and UpToDate were searched using relevant terms. The literature was assessed using the PRISMA guidelines. Inclusion criteria were: original articles written in English assessing ICG-angiography in breast reconstruction. The individual studies were evaluated according to Cochrane guidelines. RESULTS The search yielded 243 papers on ICG-A and breast reconstruction. Twenty-six of these were included for analysis. The risk of overall major complications ([OR] = 0.53, 95% confidence interval (CI) = 0.43-0.66, p = 0.00001) and overall loss of reconstruction ([OR] = 0.58, 95% CI = 0.37-0.92, and p = 0.020) was significantly lower when peroperative ICG-A was used. When using ICG-A to evaluate mastectomy flaps, a statistically lower risk of major complications ([OR] = 0.56 and p = 0.0001) and the loss of reconstruction was found ([OR] = 0.46, p = 0.006). ICG-A used in autologous breast reconstruction significantly reduced the risk of minor ([OR] = 0.62 and p = 0.001) and major complications ([OR] = 0.53 and p = 0.0028). CONCLUSIONS This is the first systematic review to analyze the use of ICG-A on both mastectomy flaps and autologous reconstruction. The results obtained in the current study indicate that the use of ICG-A in breast reconstructive procedures reduces the complications as well as the loss of reconstruction.
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Affiliation(s)
- Elisabeth Lauritzen
- Department of Plastic Surgery and Burns Treatment, Copenhagen University Hospital, Denmark.
| | - Tine Engberg Damsgaard
- Department of Plastic Surgery and Burns Treatment, Copenhagen University Hospital, Denmark
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Dinis J, Junn A, Shah R, Allam O, Mehta S, Mozaffari MA, Avraham T, Alperovich M. Abdominal subcutaneous fat thickness as a substitute for BMI in predicting complications in abdominally-based autologous breast reconstruction. Microsurgery 2021; 41:341-347. [PMID: 33720454 DOI: 10.1002/micr.30732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 02/07/2021] [Accepted: 03/03/2021] [Indexed: 11/06/2022]
Abstract
INTRODUCTION Patient selection for autologous tissue transfer for postmastectomy breast reconstruction often utilizes body mass index (BMI) to risk stratify patients, though it only estimates fat content and does not address fat distribution. This study aims to identify a measurement of abdominal subcutaneous fat thickness (ASFT) from preoperative computed tomography (CT) angiography imaging to better predict complications. METHODS A retrospective review of patients who underwent an abdominal microvascular free flap breast reconstruction was performed. The average of the bilateral distances from the lateral border of the rectus abdominus to the most proximal point of the dermis at the L4-L5 space was measured on preoperative imaging to estimate ASFT. This measurement was compared to BMI in regards to correlation with any complication, major or minor complications, and donor or recipient site complications. Statistical analysis utilized point-biserial correlations and multivariable logistic regression analyses. RESULTS Three hundred and nine cases comprising a total of 496 breast reconstructions were identified. BMI did not correlate with any of the grouped complications, while ASFT correlated with occurrence of any complication (p = .003), minor complications (p = .001), and recipient site complications (p = .001). Further analysis revealed ASFT is specifically correlated with fat necrosis (p = .005). In independent multivariable regression models, both BMI (p = .011) and ASFT (p = .001) were significant predictors of fat necrosis. The ASFT model had a BIC of 335.42 compared to the BMI model with a value of 340.89, with smaller numbers representing more predictive models. CONCLUSION Estimation of ASFT is easily performed and is a significantly better predictor of flap fat necrosis than BMI.
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Affiliation(s)
- Jacob Dinis
- Section of Plastic and Reconstructive Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Alexandra Junn
- Section of Plastic and Reconstructive Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Rema Shah
- Section of Plastic and Reconstructive Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Omar Allam
- Section of Plastic and Reconstructive Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Sumarth Mehta
- Section of Plastic and Reconstructive Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Mohammad Ali Mozaffari
- Section of Plastic and Reconstructive Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Tomer Avraham
- Section of Plastic and Reconstructive Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Michael Alperovich
- Section of Plastic and Reconstructive Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut, USA
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17
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Invited Discussion on: Fat Necrosis After DIEP Flap Breast Reconstruction: A Review of Perfusion-Related Causes. Aesthetic Plast Surg 2020; 44:1462-1465. [PMID: 32577804 DOI: 10.1007/s00266-020-01841-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Accepted: 06/14/2020] [Indexed: 10/24/2022]
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18
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Demiri EC, Tsimponis A, Pagkalos A, Georgiadou E, Goula OC, Spyropoulou GA, Dionyssiou D. Fat-Augmented Latissimus Dorsi versus Deep Inferior Epigastric Perforator Flap: Comparative Study in Delayed Autologous Breast Reconstruction. J Reconstr Microsurg 2020; 37:208-215. [PMID: 32892331 DOI: 10.1055/s-0040-1716348] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND The use of autologous tissues is considered the mainstay for delayed breast reconstruction. Aside the free abdominal flaps, which are most commonly used, the fat-augmented latissimus-dorsi (FALD) flap has been recently shown a reliable alternative option for pure autologous breast reconstruction. In this retrospective study, we aim to compare outcomes of autologous breast reconstructions using the extended FALD and deep inferior epigastric perforator flap (DIEP) flap, with an emphasis on patients' characteristics, demographic data, complications, and patients' satisfaction after a minimum 12-month follow-up. METHODS Our series consists of 135 women who underwent a delayed postmastectomy unilateral autologous breast reconstruction from 2011 to 2017: 36 patients (Group A) had an extended FALD flap and 99 (Group B) a free DIEP flap performed by the same surgeons. Demographic data, breast volume, medical history, smoking, complications, and patients' satisfaction were recorded and analyzed. Student's t-test for independent variables, Mann-Whitney U-test, and Chi-squared test were used to compare the reported variables. RESULTS Patients' age, body mass index (BMI), and pregnancy history were statistically different between groups (p < 0.001, p = 0.004, p < 0.001, respectively); younger age (35.1 vs. 41.2 years), lower BMI (25.6 vs. 28.4), and fewer pregnancies were recorded in Group A. Breast volume was also found significantly smaller in Group A patients (p = 0.009). Past medical history using the ASA physical status classification score, previous radiation therapy, history of smoking, and incidence of overall complications were similar in both groups. Overall satisfaction scores were found slightly higher, but not statistically significant, in the free-flap group (p = 0.442). CONCLUSION The use of the FALD flap may provide comparable outcome to the DIEP flap in delayed breast reconstruction in terms of complications and patients' satisfaction; it should be considered a good reconstructive option for young and thin nulliparous patients, with small to medium size opposite breast.
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Affiliation(s)
- Efterpi C Demiri
- Department of Plastic Surgery, Faculty of Medicine, School of Health Sciences, Aristotle University of Thessaloniki, Papageorgiou Hospital, Periferiaki Odos Neas Efkarpias, Thessaloniki, Greece
| | - Antonios Tsimponis
- Department of Plastic Surgery, Faculty of Medicine, School of Health Sciences, Aristotle University of Thessaloniki, Papageorgiou Hospital, Periferiaki Odos Neas Efkarpias, Thessaloniki, Greece
| | - Anastasios Pagkalos
- Department of Plastic Surgery, Faculty of Medicine, School of Health Sciences, Aristotle University of Thessaloniki, Papageorgiou Hospital, Periferiaki Odos Neas Efkarpias, Thessaloniki, Greece
| | - Eleni Georgiadou
- Department of Plastic Surgery, Faculty of Medicine, School of Health Sciences, Aristotle University of Thessaloniki, Papageorgiou Hospital, Periferiaki Odos Neas Efkarpias, Thessaloniki, Greece
| | - Olga-Christina Goula
- Department of Plastic Surgery, Faculty of Medicine, School of Health Sciences, Aristotle University of Thessaloniki, Papageorgiou Hospital, Periferiaki Odos Neas Efkarpias, Thessaloniki, Greece
| | - Georgia-Alexandra Spyropoulou
- Department of Plastic Surgery, Faculty of Medicine, School of Health Sciences, Aristotle University of Thessaloniki, Papageorgiou Hospital, Periferiaki Odos Neas Efkarpias, Thessaloniki, Greece
| | - Dimitrios Dionyssiou
- Department of Plastic Surgery, Faculty of Medicine, School of Health Sciences, Aristotle University of Thessaloniki, Papageorgiou Hospital, Periferiaki Odos Neas Efkarpias, Thessaloniki, Greece
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19
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Anker AM, Prantl L, Strauss C, Brébant V, Baringer M, Ruewe M, Vykoukal J, Klein SM. Clinical Impact of DIEP Flap Perforator Characteristics – A Prospective Indocyanine Green Fluorescence Imaging Study. J Plast Reconstr Aesthet Surg 2020; 73:1526-1533. [DOI: 10.1016/j.bjps.2020.01.019] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Revised: 12/23/2019] [Accepted: 01/05/2020] [Indexed: 11/17/2022]
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20
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Estimation of Contralateral Perfusion in the DIEP Flap by Scoring the Midline-Crossing Vessels in Computed Tomographic Angiography. Plast Reconstr Surg 2020; 145:697e-705e. [PMID: 32221198 DOI: 10.1097/prs.0000000000006684] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND In deep inferior epigastric perforator flap surgery, the amount of perfusion achievable in the contralateral side over a midline is unclear. Predicting contralateral perfusion preoperatively using computed tomographic angiography will allow efficient breast reconstruction with decreased complications. The authors used computed tomographic angiography to determine whether contralateral perfusion is related to blood vessel status across the midline. METHODS Preoperative computed tomographic angiography scans and intraoperative perfusion in patients who underwent breast reconstruction with a deep inferior epigastric perforator flap between January of 2018 and July of 2018 were checked prospectively. A vessel scoring system was prepared according to vessel density across the flap midline on the scan (grade 0, no visible vessels; grade 1, visible vessels with disconnection or could not be judged as grade 0 or 2; grade 2, definite vessels). Intraoperative flap perfusion was confirmed with indocyanine green angiography. Postoperative fat necrosis was analyzed using ultrasonography. RESULTS Ninety-four patients were analyzed. Mean maximal contralateral perfusion length was as follows: grade 0, 7.50 ± 1.89 cm; grade 1, 7.93 ± 2.01 cm; and grade 2, 10.14 ± 2.29 cm. Grade 2 had a statistically significantly greater contralateral perfusion length than grade 0 (p < 0.001) and grade 1 (p < 0.001). Fat necrosis occurred in 27.3 percent (grade 0), 19.1 percent (grade 1), and 8 percent (grade 2), which was statistically significant (p = 0.035). CONCLUSIONS A definite vessel connection across the midline (as in grade 2) in preoperative computed tomographic angiography indicates that contralateral perfusion will be sufficiently achieved. This vessel scoring system would be helpful in predicting flap perfusion and planning the surgery. CLINICAL QUESTION/LEVEL OF EVIDENCE Diagnostic, IV.
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Hillberg NS, Beugels J, van Kuijk SMJ, van der Hulst RRJW, Tuinder SMH. Increase of major complications with a longer ischemia time in breast reconstruction with a free deep inferior epigastric perforator (DIEP) flap. EUROPEAN JOURNAL OF PLASTIC SURGERY 2020. [DOI: 10.1007/s00238-019-01584-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Abstract
Background
The deep inferior epigastric artery perforator (DIEP) flap is one of the most used free flaps for postmastectomy breast reconstruction. Prolonged ischemia can result in (partial) flap loss. The aim of this study was to evaluate the association between ischemia time and postoperative complications of DIEP flap breast reconstruction.
Methods
A retrospective study of all patients who received a breast reconstructionwith aDIEP flap atMaastricht University Medical Center in theNetherlands, between January 2010 and June 2017 (n = 677). The flaps were divided into two groups: flaps with an ischemia time less than 60 min and those with 60 min or more. Recipient site complications, in particular major complications equal to re-exploration, and partial or total flap loss were the primary outcome measures.
Results
In 23.9% of the 677 included DIEP flaps, the ischemia time was 60 min or longer. Within this group, a complication of the recipient site occurred in 30.9% of the flaps. A major complication occurred in 17.3% of the flaps with 60 min or more ischemia time.With regard to the flaps with less than 60-min ischemia time, a complication occurred in 22.1% of the cases of which 8.9%would be considered amajor complication. A significant association was found between ischemia time and major complications on univariate (p value = 0.003) and multivariate analyses (p value = 0.016).
Conclusions
This study demonstrates that an ischemia time less than 60 min is associated with a significantly lower risk of major recipient site complications compared to an ischemia time of 60 min or more.
Level of evidence: Level III, therapeutic, risk/prognostic study.
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Indocyanine Green Angiography in Breast Reconstruction: Utility, Limitations, and Search for Standardization. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2020; 8:e2694. [PMID: 32537350 PMCID: PMC7253278 DOI: 10.1097/gox.0000000000002694] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Accepted: 01/17/2020] [Indexed: 11/25/2022]
Abstract
Supplemental Digital Content is available in the text. During reconstructive breast surgery, intraoperative assessment of tissue perfusion has been solely based on subjective clinical judgment. However, in the last decade, intraoperative indocyanine green angiography (ICGA) has become an influential tool to visualize blood flow to the tissue of interest. This angiography technique produces real-time blood flow information to provide an objective assessment of tissue perfusion.
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Liu Z, Li Z, Peng X, Zhou B, Tang Y, Wu P, Song D, Lü C, Peng W, Li H, Ou Y, Xu A. [Multivariable analysis for flap-related complications in autologous breast reconstruction and economic analysis of intraoperative indocyanine green angiography]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2020; 34:92-97. [PMID: 31939242 DOI: 10.7507/1002-1892.201906023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Objective To investigate the influencing factors of flap-related complications and the economic benefits of intraoperative indocyanine green (ICG) angiography in the patients undergoing autologous breast reconstruction. Methods Between July 2013 and June 2018, the clinical data of 150 patients (152 breasts) who met the selection criteria after autologous breast reconstruction were analyzed retrospectively. Ten factors including age, body mass index, preoperative neoadjuvant chemotherapy (NC), chest radiation history, diabetes, abdominal operation history, chest wall reconstruction, reconstruction timing, flap type, intraoperative ICG angiography were analyzed by univariate analysis. Significant variables found in univariate analysis were used to perform backward multivariate logistic regression of flap related complications and local necrosis. According to the above multi factor analysis results, the patients were divided into 4 groups: ICG+NC group (group A), ICG+non-NC group (group B), non-ICG+NC group (group C), non-ICG+non-NC group (group D). The average extra costs of surgical treatment (including ICG imaging cost+cost of handling flap related complications) of each group was calculated. Results All the 152 flaps survived. There were 33 flap-related complications, including 22 regional necrosis, 9 regional infection, 5 hematoma, 5 simple fat liquefaction, and 2 anasto-motic thrombosis. Univariate analysis showed that preoperative NC, flap type, and intraoperative ICG angiography had significant influence on the incidence of flap-related complications ( P<0.05). Multivariate analysis showed that preoperative NC and non-ICG angiography were the risk factors of flap-related complications ( P<0.05), and also the risk factors of regional flap necrosis ( P<0.05). For patients who had NC, intraoperative ICG angiography could greatly save the average extra costs. The average extra costs in group A was 1 378 yuan less than that in group C. For the patients without NC, intraoperative ICG angiography would increase the average extra costs, which was 747 yuan in group B more than that in group D. Conclusion In autologous breast reconstruction, ICG angiography can reduce the incidence of flap-related complications, especially the incidence of regional flap necrosis, while NC is the opposite. For patients without NC, ICG angiography is not cost-effective but still can be used if conditions permit. However, for those with NC, ICG angiography is cost-effective and recommended.
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Affiliation(s)
- Zeyang Liu
- Department of Oncology Plastic Surgery/Head & Neck Surgery, the Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University/Hunan Cancer Hospital, Changsha Hunan, 410013, P.R.China
| | - Zan Li
- Department of Oncology Plastic Surgery/Head & Neck Surgery, the Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University/Hunan Cancer Hospital, Changsha Hunan, 410013,
| | - Xiaowei Peng
- Department of Oncology Plastic Surgery/Head & Neck Surgery, the Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University/Hunan Cancer Hospital, Changsha Hunan, 410013, P.R.China
| | - Bo Zhou
- Department of Oncology Plastic Surgery/Head & Neck Surgery, the Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University/Hunan Cancer Hospital, Changsha Hunan, 410013, P.R.China
| | - Yuanyuan Tang
- Department of Oncology Plastic Surgery/Head & Neck Surgery, the Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University/Hunan Cancer Hospital, Changsha Hunan, 410013, P.R.China
| | - Peng Wu
- Department of Oncology Plastic Surgery/Head & Neck Surgery, the Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University/Hunan Cancer Hospital, Changsha Hunan, 410013, P.R.China
| | - Dajiang Song
- Department of Oncology Plastic Surgery/Head & Neck Surgery, the Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University/Hunan Cancer Hospital, Changsha Hunan, 410013, P.R.China
| | - Chunliu Lü
- Department of Oncology Plastic Surgery/Head & Neck Surgery, the Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University/Hunan Cancer Hospital, Changsha Hunan, 410013, P.R.China
| | - Wen Peng
- Department of Oncology Plastic Surgery/Head & Neck Surgery, the Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University/Hunan Cancer Hospital, Changsha Hunan, 410013, P.R.China
| | - Hui Li
- Department of Oncology Plastic Surgery/Head & Neck Surgery, the Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University/Hunan Cancer Hospital, Changsha Hunan, 410013, P.R.China
| | - Yan Ou
- Department of Oncology Plastic Surgery/Head & Neck Surgery, the Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University/Hunan Cancer Hospital, Changsha Hunan, 410013, P.R.China
| | - Anji Xu
- Department of Oncology Plastic Surgery/Head & Neck Surgery, the Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University/Hunan Cancer Hospital, Changsha Hunan, 410013, P.R.China
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When to assess the DIEP flap perfusion by intraoperative indocyanine green angiography in breast reconstruction? Breast 2019; 47:102-108. [DOI: 10.1016/j.breast.2019.07.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Revised: 07/28/2019] [Accepted: 07/31/2019] [Indexed: 11/20/2022] Open
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