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

The Influence of the Superficial Venous System on DIEP Flap Drainage in Breast Reconstruction

BACKGROUND

 Autologous tissue has become the gold standard in breast reconstruction. The use of a deep inferior epigastric perforator (DIEP) flap has the advantages of giving a natural appearance to the reconstructed breast and being associated with lower morbidity at the donor site when compared with the transverse rectus abdominis myocutaneous flap. Venous complications such as venous thrombosis and insufficiency remain the main causes of flap loss and surgical revisions. The aim of this study was to evaluate the influence of superficial venous drainage of the DIEP flap and the addition of a second venous anastomosis have on flap survival.

METHODS

 This was a retrospective cohort study collected from a prospective database maintained by our institution. Data was obtained from the medical records of female patients who underwent mastectomy and breast reconstruction with a DIEP flap between March 2010 and March 2017. We evaluated 137 DIEP patients with unilateral breast reconstructions. In 64 (46.7%) the deep venous system was chosen and 73 (53.3%) had an additional superficial vein anastomosed.

RESULTS

 Out of the 137 patients evaluated, there were 16 (11.67%) cases of revision, 14 (10.21%) were due to venous thrombosis. Twelve cases (8.75%) of flap loss were reported. Reoperation rate was lower in the dual venous drainage group when compared with the single venous drainage group (p = 0.005), as was the rate of flap loss (p = 0.006) and reoperation due to venous thrombosis (p = 0.002). Out of the 125 DIEP flaps, fat necrosis was clinically identified in 7 (5.1%) cases, and the rate was lower in the dual venous drainage system group (p = 0.01).

CONCLUSION

 Dual venous drainage of a DIEP flap appears to reduce the rates of venous thrombosis, reoperation, total flap loss, and fat necrosis.

[Cytosteatonecrosis after breast reconstruction by fat flap with or without ischemic preconditioning]

INTRODUCTION

Cytosteatonecrosis (CTN) is a frequent postoperative complication after breast autologous reconstruction using DIEP (deep inferior epigastric perforator) flap. CTN radiological diagnostic reveals different types of lesions, as nodes or extended fat necrosis, which become in some cases infected, or pass for tumor recurrence after breast cancer treatment. CTN is caused by intraoperative ischemia of the flap, and no current method can prevent postoperative CTN development after DIEP breast reconstruction. Mechanical ischemic preconditioning, consisting in intraoperative briefs consecutive cycles of ischemia reperfusion using vascular clamp upon the graft pedicle, is used in transplantation surgery. This procedure improves the graft tolerance towards ischemic surgical lesions. The aim of this retrospective observational study was to assess PCIM effects on CTN development after DIEP surgery, comparing CTN occurrence after breast reconstruction using DIEP flap with or without intraoperative PCIM.

MATERIAL AND METHODS

All patients breats reconstructed using DIEP flap between novembre 2020 and may 2022, presenting 6 months postoperative breast echography were retrospectively included. Primary outcome was the ultrasonic existence of CTN, according to the Wagner classification. Clinical data, postoperative outcomes such as infection, hematoma or surgical revision, and length of stay in hospital were also recorded.

RESULTS

Twenty nine patients among which 8 PCIM were included. CTN occurrence rate after PCIM (25%) was quite lower than CTN rate without PCIM (71,4%), although the difference was not significant (P=0,088). Other postoperative complications rates were not significantly different with or without PCIM.

CONCLUSION

PCIM seems to improve CTN occurrence after DIEP breast reconstruction, improving fat flap tolerance to ischemic perioperative lesions. Those preliminary results need to be confirmed with clinical prospective study.

Do bilateral procedures further increase the complications for autologous breast reconstruction in obese patients?

BACKGROUND

Obesity is known to be associated with high complication rates. The aim of this study was to evaluate the effect of bilateral procedures on complication rates in obese patients undergoing autologous breast reconstruction with deep inferior epigastric perforator flaps.

METHODS

Medical records of patients undergoing autologous breast reconstruction between January 2017 and December 2019 were retrospectively reviewed. Patients were divided into two groups according to their body mass index (BMI): Group 1 (BMI > 30) and Group 2 (BMI < 30). Group 1 was further divided into 3 subgroups: Group 1a (bilateral reconstruction), Group 1b (unilateral reconstruction), and Group 1c (unilateral reconstruction and contralateral symmetrization). Outcomes and complication rates were compared between groups.

RESULTS

Ninety-one patients (with 119 free flaps) were followed up between 6 and 12 months. Length of hospital stay, smoking rates, and age were similar in all groups. Group 1 had significantly more rates of wound dehiscence (p = 0.024), mastectomy skin flap necrosis (p = 0.019), and re-operation (p = 0.033). The operation time was significantly higher in group 1 (p = 0.003). There was no significant difference between group 1 and group 2 in terms of hematoma-seroma formation, flap loss, and pulmonary thromboembolism rates. When obese subgroups were compared, no significant difference was observed in terms of complications.

CONCLUSION

In our series, microvascular breast reconstruction was associated with more complication rates in obese patients. However, bilateral procedures in the obese patient group did not significantly increase risk of complications as compared to unilateral procedures. By taking appropriate measures bilateral procedures can be performed in obese patients without additional risks.

Near-infrared fluorescence angiography with indocyanine green for perfusion assessment of DIEP and msTRAM flaps: A Dutch multicenter randomized controlled trial

Background

A common complication after a DIEP flap reconstruction is the occurrence of fat necrosis due to inadequate flap perfusion zones. Intraoperative identification of ischemic zones in the DIEP flap could be optimized using indocyanine green near-infrared fluorescence angiography (ICG-NIR-FA). This randomized controlled trial aims to determine whether intraoperative ICG-NIR-FA for the assessment of DIEP flap perfusion decreases the occurrence of fat necrosis.

Design/methods

This article describes the protocol of a Dutch multicenter randomized controlled clinical trial: the FAFI-trial. Females who are electively scheduled for autologous breast reconstruction using DIEP or muscle-sparing transverse rectus abdominis muscle (msTRAM) flaps are included. A total of 280 patients will be included in a 1:1 ratio between both study arms. In the intervention arm, the intraoperative assessment of flap perfusion will be based on both regular clinical parameters and ICG-NIR-FA. The control arm consists of flap perfusion evaluation only through the regular clinical parameters, while ICG-NIR-FA images are obtained during surgery for which the surgeon is blinded. The main study endpoint is the difference in percentage of clinically relevant fat necrosis between both study arms, evaluated two weeks and three months after reconstruction.

Conclusion

The FAFI-trial, a Dutch multicenter randomized controlled clinical trial, aims to investigate the clinical added value of intraoperative use of standardized ICG-NIR-FA for assessment of DIEP/msTRAM flap perfusion in the reduction of fat necrosis.

Clinical trial registration number

NCT05507710; NL 68623.058.18.

Periumbilical Anatomy of Scarpa's Fascia: Rationale Behind a "Modified Scarpa's" Abdominal Closure Technique

BACKGROUND

Intraoperative observation of Scarpa's fascia (SF) has suggested attenuation in the periumbilical region. This study's purpose was to objectively evaluate SF anatomy in the periumbilical region and assess clinical outcomes of a novel, modified SF closure technique of transverse abdominal wall incisions that only reapproximates SF where it is definitively present.

METHODS

Women were identified who had undergone abdominal magnetic resonance (MR) angiography before their abdominal-based autologous breast reconstruction that used the modified SF closure technique. Statistical analysis of SF presentation on the MR images was performed. Intraoperative measurements from dissected panniculectomy specimens were used to validate MR analysis. Donor site complications were recorded in patients undergoing modified SF closure.

RESULTS

Sixty-six patients were included in the retrospective MR imaging analysis; this revealed an average attenuation of SF of 4.7 cm (SEM = 0.25 cm), 4.5 cm (SEM = 0.23 cm), 4.6 cm (SEM = 0.23 cm), and 4.2 cm (SEM = 0.22 cm) to the left of, right of, cranial to, and caudal to the umbilicus, respectively. The mean surface area of radiologic SF absence was 56.3 cm 2 (SEM = 3.57 cm 2 ). There was a significant difference in SF presentation based on patient age ( P = 0.013) and body mass index ( P = 0.005). Five of the 66 patients (7.6%) experienced abdominal closure site complications.

CONCLUSIONS

This study objectively confirms that there is attenuation of SF in the periumbilical region, describes a novel SF closure technique, and provides evidence to support its adoption when closing transverse abdominal wall incisions.

Impact of smoking on donor site following rectus flap harvest for head and neck reconstruction

OBJECTIVES

The rectus abdominis myocutaneous free flap has been widely used as a reconstructive option in head and neck reconstruction with great success. Challenging the popular assumption, this study sought to examine the effects of smoking on donor site complications in this population.

METHODS

Multi-institution retrospective study of 103 patients (50 active smokers, 28 former and 25 never smoked).

RESULTS

Overall complication rate was 14.5 %. Hernia rate 4.8 %, evisceration 0 %, dehiscence 2.9 %, infection 6.7 %. Smoking history did not significantlly influence complication rates (chi square test, p = 0.33). Abdominal wall closure technique also did not influence the complication rate (chi square test, p = 0.58).

CONCLUSIONS

The rectus abdomonis myocutaneous free flap has an acceptable complication rate that does not appear to be influenced by smoking history. While patients should be counseled regarding smoking cessation, smoking habits should not delay treatment nor obviate consideration of rectus flap utilization.

Evaluation of Morphometric Measurements on Preoperative CT Angiograms to Determine Risk of Abdominal Donor Site Complications—A Retrospective Review of 174 Patients

Introduction: Autologous breast reconstruction remains a popular surgical option following mastectomy; however, it is not without complications. Preoperative CT angiograms (CTAs) are often obtained for surgical planning, and morphometric data such as fat and muscle distribution can be measured. This study aimed to assess if CTA morphometric data predicts abdominal donor site complications in patients undergoing abdominally based autologous breast reconstruction. Methods: A retrospective cohort study was performed for patients who underwent abdominally based autologous breast reconstruction from 2013 to 2018. Along with population and operative characteristics, preoperative morphometric variables were assessed for the following: subcutaneous adipose tissue, visceral adipose tissue, skeletal muscle area and index, rectus and psoas cross-sectional area, and bone density. Statistical comparison to abdominal donor site complications was performed using logistic regression analysis for every 100-unit change. Results: A total of 174 patients were included in this study. Visceral adipose tissue was significantly associated with the development of infection ( P = .005), epidermolysis ( P = .031), and seroma ( P = .04). Subcutaneous adipose tissue, skeletal muscle index, cross-sectional muscle area, and bone density were not associated with abdominal donor site complications. Obesity ( P = .024), history of smoking ( P = .049), and the number of perforators harvested ( P = .035) significantly increased the likelihood of delayed abdominal healing. Conclusions: This study demonstrates that increased visceral adipose tissue, as measured by CTA, is significantly associated with an increased risk of abdominal donor site complications. CTA morphometric data and identifying high-risk patient characteristics can help guide preoperative counseling and better inform surgical risks.

Morbidity of the Donor Site and Complication Rates of Breast Reconstruction with Autologous Abdominal Flaps: A Systematic Review and Meta-Analysis

Background. Numerous studies have evaluated the use of autologous abdominal tissue for breast reconstruction; nevertheless, complications and donor site morbidity rates vary significantly. The study aims to compare the literature regarding morbidity of the donor site and complication rates of breast reconstruction with autologous abdominal flaps. Methods. The databases of MEDLINE, EBSCO, Scopus, Wiley Library, and Web of Sciences were searched for studies that compared different flaps in terms of complications and donor site morbidity. The procedures studied included pedicled transverse rectus abdominis myocutaneous flap (pTRAM), free TRAM (fTRAM), deep inferior epigastric perforator (DIEP), and superficial inferior epigastric artery perforator (SIEA) flaps. A total of 34 studies were included. Of these, 28 were retrospective studies and 9 were prospective cohort studies. Results. When compared to DIEP, fTRAM flaps were found to have a decreased incidence of flap fat necrosis, hematoma, and total thrombotic events, yet a higher risk of donor site hernia/bulging. pTRAM flaps were also associated with an increased risk of hernia/bulging at the donor site, as well as wound infection, yet flap hematoma was less common. On the other hand, SIEA flaps showed the lowest risk of donor site hernia/bulging while still having a high risk of wound infection. Conclusion. fTRAM procedures comparatively had the least complications. However, regarding flap choice, patients would benefit most from a case-by-case analysis, taking into consideration individual risk factors and preferences.

A Bayesian Network Meta-Analysis of Complications Related to Breast Reconstruction Using Different Skin Flaps After Breast Cancer Surgery

BACKGROUND AND OBJECTIVES

As the incidence of breast cancer rises, the number of mastectomy surgeries surges, so does the importance of postoperative breast reconstruction. The implementation of autologous flap restoration methods is becoming prevalent, although which is the best flap remains controversial. As a result, we performed a Bayesian network meta-analysis to compare the eight most common flap in the reconstruction processor of breast cancer surgery. Our findings may help surgeons decide which skin flaps to use for breast reconstruction.

METHODS

We searched PubMed, Medline, Embase, and the Cochrane library for relevant literature. For our Bayesian network meta-analysis, we scrutinized 37 papers and evaluated the postoperative complications of eight commonly used breast reconstruction procedures. We also registered this study on PROSPERO, with the number CRD42021251989.

RESULTS

A total of 21,184 patients were included in this Bayesian network meta-analysis from 37 different studies. The results demonstrate that TRAM flaps are more prone to complications such as hernias in the abdominal wall and blood flow problems. Hematoma and seroma are more likely to follow LDP flaps. Combining LDP flaps with a prosthetic or autologous adipose tissue does not enhance the risk of postoperative problems appreciably. Fat liquefaction are relatively common in DIEP.

CONCLUSIONS

After breast reconstruction, several skin flaps can be employed as clinical choices. TRAM flaps are not recommended for patients with a weak abdominal wall structure, although LDP flaps or SIEA flaps can be considered instead. We do not advocate LDP flaps for patients who have had breast surgery because of the higher risk of hematoma or seroma, but DIEP flaps or LAP flaps can be utilized instead. We do not propose DIEP flaps for individuals who are at a higher risk of postoperative fat liquefaction, but LDP flaps or SIEA flaps can be used instead. However, this Bayesian network meta-analysis has limitations, and further randomized controlled trials are needed to confirm its findings.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Assessment of deep inferior epigastric perforator flap perfusion with near-infrared fluorescence: A pilot study and description of a standardized working protocol

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.

Application of intraoperative indocyanine green angiography for detecting flap congestion in the use of free deep inferior epigastric perforator flaps for breast reconstruction

BACKGROUND

The use of intraoperative indocyanine green (ICG) angiography has been well documented for confirmation of arterial perfusion in transferred free flaps. However, no previous report has yet focused on whether ICG angiography can be used to detect congestion in free flaps. The present report investigates the feasibility of ICG angiography for detecting flap congestion intraoperatively through illustrative cases.

METHODS

From September 2019 to September 2020, 65 consecutive female patients who underwent breast reconstructions using a free deep inferior epigastric perforator (DIEP) flap were enrolled in this study. Forty-eight patients with 52 DIEP flaps were eligible for the study after application of the exclusion criteria. ICG angiography was performed after elevation of the flap, after completion of the anastomoses, and after inset of the flap.

RESULTS

In five cases (9.6%), an inadequate highlight was demonstrated with ICG angiography performed after flap elevation. All such cases were deemed congestive since robust bleeding was observed with the prick test. ICG angiography demonstrated sufficient highlight of the flap after removal of the clamp on the superficial inferior epigastric vein. In two cases (4.2%), kinking of the pedicle vein of the DIEP flap was found with ICG angiography performed after inset of the flap. In both cases, the pedicle and the flap were reinset. All flaps survived completely postoperatively.

CONCLUSION

ICG angiography can detect flap congestion, and the proposed 3-step protocol is useful for the prevention of postoperative complications.

Fat Necrosis After DIEP Flap Breast Reconstruction: A Review of Perfusion-Related Causes

INTRODUCTION

Fat necrosis is a common complication for the deep inferior epigastric perforator (DIEP) flap. A thorough understanding of the factors associated with fat necrosis will aid operative planning for reconstructive surgeons.

METHODS

A systematic review of the literature was performed between January 1989 and April 2019. Studies were included if they reported on fat necrosis in DIEP flap or evaluated the perfusion of the DIEP flap. Twenty-eight out of 312 studies met the inclusion and exclusion criteria.

RESULTS

Fat necrosis rates ranged from 12.0 to 45.0% on clinical examination within the literature. The four main perforator-specific factors identified included perforator perfusion zones, perforator location, perforator number and venous congestion. Medial row perforators have a wider perfusion zone, while lateral row perforators have a narrow perfusion zone. Holm zone III has a higher rate of fat necrosis compared to Holm zone II. One to two perforators and more than five perforators and a Type III atypical connection between the superficial and deep venous system had a higher rate of fat necrosis.

CONCLUSION

The DIEP flap should incorporate between two and three perforators of a substantial calibre; Holm zone III should be excluded if able and careful review of the pre-operative imaging should be performed to analyse the connections between the deep and superficial venous system. There are multiple perfusion-related factors to consider when planning the DIEP flap and ultimately a patient-specific approach to the vascular anatomy is essential.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

A comparative study for the rate of adverse outcomes in unilateral and bilateral abdominal flap breast reconstruction: A meta-analysis

BACKGROUND

Adverse outcomes after unilateral vs bilateral breast reconstruction involve an unknown level of risk that warrants thorough investigation.

METHODS

To address this research need, PubMed, Ovid, Medline, EMBASE, and Scopus databases were searched through systematically from January 1, 1990, to January 1, 2019 to retrieve the relevant studies on the risk of postoperative complications after unilateral vs bilateral abdominal flap breast reconstruction. According to the pre-designed inclusion criteria, available data were extracted from the relevant studies, and then analyzed comparatively in order to identify the relative risk (RR) and 95% confidence intervals (CI) applying either a random or a fixed effects model.

RESULTS

Eventually, 20 studies involving 8122 female subjects met the inclusion criteria. It was found that unilateral reconstruction involved a significantly higher risk of flap loss (RR: 1.56, 95% CI: 1.21-2.00; P < .05) and fat necrosis (RR: 1.60, 95% CI: 1.23-2.09; P < .05) compared to bilateral reconstruction, while bilateral reconstruction involved a greater risk of abdominal hernia/bulge (RR: 1.67, 95% CI: 1.25-2.24; P < .05). The risk was found to be higher following bilateral free transverse rectus abdominis myocutaneous (fTRAM) flaps in comparison with deep inferior epigastric perforator (DIEP) flaps (RR: 2.62, 95% CI: 1.33-5.15; P < .05).

CONCLUSION

The risk of postoperative flap complications in unilateral breast reconstruction is significantly higher than that in bilateral reconstruction. Contrarily, the abdominal complications were significantly higher in the bilateral group vs the unilateral group. Meanwhile, the risk of abdominal hernia/bulge complication after bilateral breast reconstruction was significantly higher with fTRAM vs DIEP. Therefore, DIEP flaps are recommended in priority for bilateral breast reconstruction, unless specifically contraindicated.

A Meta-analysis of Clinical, Patient-Reported Outcomes and Cost of DIEP versus Implant-based Breast Reconstruction

Comparative data on clinical outcomes and cost of deep inferior epigastric perforator (DIEP) and implant-based reconstruction (IBR) are limited. We conducted a Preferred Reporting Items for Systematic Review and Meta-analysis-compliant systematic review and meta-analysis to compare clinical, patient-reported outcomes (PROs) and cost.

A systematic review of donor site aesthetic and complications after deep inferior epigastric perforator flap breast reconstruction

Background

The deep inferior epigastric perforator flap (DIEP) has gained widespread popularity in autologous breast reconstruction due to its natural aesthetic results and muscle-sparing design. However, donor site results regarding aesthetic outcome are often less favorable. Despite several studies on surgical technique and improvements of flap harvest, only a small number of studies addressing donor site aesthetic exist.

Methods

A systematic review was performed on donor site aesthetic after DIEP flap harvest according to the PRISMA guidelines. Secondary interests were abdominal wall morbidity and complication rates in general. The following electronic databases were included to identify relevant studies: Medline, Embase, PubMed, Cochrane, and Web of Science.

Results

The search yielded 95 articles for full-text analysis, with only four key studies found on donor site aesthetic specifically. Regarding complication rates, the overall rate of abdominal hernia ranges from 0 to 7.1%. Abdominal bulging occurs in 2.3% to 33%. Besides abdominal wall integrity, wound dehiscence (12-39%), seroma (1-48%), hematoma (1-15%), infections (1-12%), fat necrosis (0-11%) and umbilical necrosis (2-3%) significantly impair donor site aesthetic.

Conclusions

This systematic review reveals that the topic of donor site aesthetic and potential improvement of results has largely been neglected in the past decade. This study provides a thorough evaluation of potential problems that plastic surgeons may encounter and includes recommendations to improve results.

Innovative DIEP flap perfusion evaluation tool: Qualitative and quantitative analysis of indocyanine green-based fluorescence angiography with the SPY-Q proprietary software

BACKGROUND

Perfusion-related complications remain the most common concern in DIEP flap breast reconstruction. Indocyanine green-based fluorescence angiography can be used for the real-time intra operative assessment of flap perfusion. The SPY Elite system is the most widely used device in this setting. The main objective was to describe the use of SPY-Q proprietary software to perform qualitative and quantitative analysis of flap perfusion.

METHODS

This retrospective cohort study was performed at the Curie Institute between 2013 and 2017. We included patients undergoing unilateral DIEP flap breast reconstruction for whom indocyanine green-based angiography videos were of sufficient quality for analysis. Videos were recorded with the SPY Elite System and analyzed with SPY-Q proprietary software.

RESULTS

We included 40 patients. We used real-time dynamic color analysis to describe three different patterns of flap perfusion. SPY-Q proprietary software provides quantitative flap perfusion parameters. Our quantitative analysis confirmed that zone I is the best perfused part of the flap and zone IV the less perfused one. There was no significant association between flap perfusion pattern and perforator anatomy, patients' clinical characteristics or postoperative outcomes. After exploratory univariate analysis, quantitative perfusion parameters were significantly impaired in young patients with diabetes mellitus or under hormone therapy by tamoxifen.

CONCLUSIONS

We here describe a new approach to assess DIEP flap perfusion using the SPY Elite System proprietary software. It provides interesting qualitative and quantitative analysis that can be used in further studies to precisely assess DIEP flap perfusion.

[Surgical revision in case of DIEP failure in breast reconstruction]

INTRODUCTION

Immediate or delayed breast reconstruction by deep inferior epigastric perforant flap (DIEP) is a frequent and widespread autologous breast reconstruction technique that presents a risk of failure inherent in its microsurgical nature. The main objective was to evaluate the interest of surgical revision in case of DIEP failure, the secondary objective was to evaluate the consequences of surgical revision on the subsequent management.

MATERIALS AND METHODS

This is a retrospective monocentric and single-operator analytical study of 167 unilateral DIEPs carried out from 2008 to 2016. Two groups were compared: success of DIEP without revision versus DIEP requiring a revision that resulted in success or failure. After analyzing the failure and recovery rates of DIEP, we compared the transfusion rate, total operating time, hospitalization time, and final breast reconstruction in the two groups.

RESULTS

One hundred and sixty-seven DIEPs were performed from 2008 to 2016 in 167 women, 18 revisions were reported (10.7%), 12 revisions were successfully reported (7.2%) 6 failures were reported after revision (3.6%). Surgical revision allows the flap to be rescued in 67% of cases. Revision increases the risk of blood transfusion by a factor of 12 (OR=12.24 [95% CI=3.74-43.17] P<0.05). Revision or failure doubles the total operating time (281.8min [170-570] vs. 577.8min [285-860] P<0.05) and increases hospitalization time by 2.5days compared to DIEP's initial success (5.74days [4-9] vs. 8.33days [5-17] P<0.05). Fifty percent of patients choose another type of breast reconstruction after DIEP failure.

CONCLUSION

DIEP is a reliable microsurgical breast reconstruction technique, failure can be prevented in two thirds of cases by monitoring and early reoperation.

The use of plasmakinetic cautery compared to conventional electrocautery for dissection of abdominal free flap for breast reconstruction: single-centre, randomized controlled study

Background

The plasmakinetic cautery is a surgical dissection instrument that combines scalpel-like cutting precision with electrocautery-like haemostasis properties, and operates at lower temperatures (40-170 °C) than conventional electrocautery (200-350 °C). The aim of this study is to evaluate the clinical benefits of using plasmakinetic cautery in abdominal free flap dissection for breast reconstruction.

Methods

Forty women undergoing abdominal-based microsurgical breast reconstruction (DIEP/MS-TRAM) were randomized to plasmakinetic cautery (n=20) or conventional electrocautery (n=20) for dissection of the abdominal free flap. Total abdominal wound drainage volume/duration, operation time and complications such as seroma and haematoma were examined.

Results

Age, body mass index, type of reconstruction and abdominal flap weight were similar in both groups. Mean abdominal drainage volume was (279±262) mL in conventional electrocautery group and (294±265) mL in plasmakinetic cautery group (P=0.853). Plasmakinetic cautery group mean drainage duration (4.3±2.2 days) was no difference compared to conventional diathermy group (3.8±2.0 days, P=0.501). Mean operation time in the conventional electrocautery group and plasmakinetic cautery group was 157±50 vs. 174±70 min respectively (P=0.195). There was more seroma detected in the conventional electrocautery group compared to plasmakinetic cautery group at days 7, 14 and 42 post-operation, but this was not statically significant. 2 haematomas in conventional diathermy group and 1 haematoms in the plasmakinetic cautery group required evacuation.

Conclusions

This study demonstrates that there are no significant differences between the use of plasmakinetic cautery and conventional electrocautery for abdominal free flap dissection.

Risk factors and timing of postoperative hematomas following microvascular breast reconstruction: A prospective cohort study

BACKGROUND

Microvascular free tissue transfer has become the gold standard for breast reconstruction. While safe and reliable, there are operative complications, with hematomas developing under the free flap among the more common. These can compromise flap viability, lead to hemodynamic instability and infection. This study aims to identify predictors of hematomas following free-flap breast reconstruction.

METHODS

A prospective study was undertaken of patients undergoing autologous free-flap breast reconstruction over a 4-year period. Precise times to hematoma formation, age, arterial and venous anastomosis time, and anastomosis length were recorded and analyzed for association with time to hematoma formation.

RESULTS

One thousand two hundred twelve flaps were undertaken in 1,070 patients during the period of review. Seventy-one (5.8%) flaps were taken back to theater for hematomas. Immediate reconstruction had a significantly higher hematoma rate compared to delayed reconstruction 7.4% versus 5.2% (p < .001). It is noted that there were two main peaks for time to develop hematomas-less than 4 hr postsurgery and between 12 and 15 hr postsurgery.

CONCLUSION

Hematomas are a complication, which must be managed with prompt return to theater to ensure flap salvage and patient stabilization. Predictors for hematoma are presented, with hematomas most likely encountered within the first 12 hr of surgery.

Myth-Busting the DIEP Flap and an Introduction to the Abdominal Perforator Exchange (APEX) Breast Reconstruction Technique: A Single-Surgeon Retrospective Review

Supplemental Digital Content is available in the text.

This and Related “Classic” Articles Appear on Prsjournal.com for Journal Club Discussions.

Background:

Anatomical variations in perforator arrangement may impair the surgeon’s ability to effectively avoid rectus muscle transection without compromising flap perfusion in the deep inferior epigastric artery perforator (DIEP) flap.

Methods:

A single surgeon’s experience was reviewed with consecutive patients undergoing bilateral abdominal perforator flap breast reconstruction over 6 years, incorporating flap standardization, pedicle disassembly, and algorithmic vascular rerouting when necessary. Unilateral reconstructions were excluded to allow for uniform comparison of operative times and donor-site outcomes. Three hundred sixty-four flaps in 182 patients were analyzed. Operative details and conversion rates from DIEP to abdominal perforator exchange (“APEX”) arms of the algorithm were collected. Patients with standardized DIEP flaps served as the controlling comparison group, and outcomes were compared to those who underwent abdominal perforator exchange conversion.

Results:

The abdominal perforator exchange conversion rate from planned DIEP flap surgery was 41.5 percent. Mean additional operative time to use abdominal perforator exchange pedicle disassembly was 34 minutes per flap. Early postsurgical complications were of low incidence and similar among the groups. One abdominal perforator exchange flap failed, and there were no DIEP flap failures. One abdominal bulge occurred in the DIEP flap group. There were no abdominal hernias in either group. Fat necrosis rates (abdominal perforator exchange flap, 2.4 percent; DIEP flap, 3.4 percent) were significantly lower than that historically reported for both transverse rectus abdominis musculocutaneous and DIEP flaps.

Conclusions:

This study revealed no added risk when using pedicle disassembly to spare muscle/nerve structure during abdominal perforator flap harvest. Abdominal bulge/hernia was nearly completely eliminated. Fat necrosis rates were extremely low, suggesting benefit to pedicle disassembly and vascular routing exchange when required.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Therapeutic, III.

Intraoperative Indocyanine Green Angiography for Fat Necrosis Reduction in the Deep Inferior Epigastric Perforator (DIEP) Flap

BACKGROUND

Fat necrosis is a frequent complication (up to 62.5%) of microsurgical breast reconstruction using the deep inferior epigastric perforator (DIEP) flap. This could have important clinical and psychological repercussions, deteriorating the results and increasing reconstruction costs.

OBJECTIVES

The aim of this study was to demonstrate the intraoperative use of indocyanine green angiography (ICGA) to reduce fat necrosis in DIEP flap.

METHODS

Sixty-one patients who underwent unilateral DIEP flap procedures for breast reconstruction after oncological mastectomy were included (24 cases with intraoperative use of ICGA during surgery, 37 cases in the control group). The follow-up period was 1 year after surgery. The association between the use of ICGA and the incidence of fat necrosis in the first postoperative year, differences in fat necrosis grade (I-V), differences in fat necrosis requiring reoperation, quality of life, and patient satisfaction were analyzed.

RESULTS

The incidence of fat necrosis was reduced from 59.5% (control group) to 29% (ICG-group) (P = 0.021) (relative risk = 0.49 [95% CI, 0.25-0.97]). The major difference was in grade II (27% vs 2.7%, P = 0.038). The number of second surgeries for fat necrosis treatment was also reduced (45.9% vs 20.8%, P = 0.046). The ICG group had higher scores on the BREAST-Q.

CONCLUSIONS

Intraoperative ICGA is a useful technique for reconstructive microsurgery that might improve patient satisfaction and reduce the incidence of fat necrosis by half as well as reduce its grade, especially in small fat necrosis cases; consequently, ICGA could reduce the number of secondary surgeries for treatment of fat necrosis.

LEVEL OF EVIDENCE: 4

Free tissue transfer with the free rectus abdominis flap in high-risk patients above 65 years: A retrospective cohort study

BACKGROUND

Though technically feasible, free tissue transfer carries the risk of perioperative morbidity and mortality in elderly patients. To minimize the operative treatment time and complication rates, we choose the rectus abdominis muscle (RAM) flap.

METHODS

Between 2012 and 2017, 34 patients (mean age: 74±7 years, range: 65-89 years) with comorbidities underwent defect reconstruction with a free RAM flap. Recipient-sites were: lower extremity (65%), trunk (18%), upper extremity (12%), and head and neck (6%).

RESULTS

The ASA status was 2 in 11 patients, 3 in 21 patients, and 4 in 2 patients. Twenty patients (59%) received additional vascular surgery. Three patients (9%) underwent simultaneous restoration of fractures. The mean operative time (OT) was 325±75 min. There was no total flap loss. Partial flap loss occurred in one patient (3%). The incidence of surgical and medical complications was 32% and 38%: 11 patients experienced a total of 22 surgical complications, of which 15 were major (requiring additional surgery) and 7 minor (conservative treatment). One patient died postoperatively because of progressive respiratory failure. Prolonged OT was highly associated with hematoma formation requiring re-operation (p = 0.01). ASA status was a significant predictor for postoperative critical care monitoring (p = 0.03). Reconstruction was successful in 31 out of 34 patients (91%) during a mean follow-up time of 17.7 ± 8.8 months (range: 2-51 months).

CONCLUSION

The free RAM flap has proven as a reliable and efficient tool in the armamentarium of reconstructive microvascular surgeons with some advantages in the treatment of multimorbid patients older than 65 years.

Predicting venous congestion before DIEP breast reconstruction by identifying atypical venous connections on preoperative CTA imaging

BACKGROUND

Venous congestion is the principle cause of flap failure after microsurgical breast reconstruction. We aim to correlate preoperative computed tomography angiography (CTA) findings with postoperative venous congestion to predict patients at risk of congestion.

METHODS

All patients undergoing deep inferior epigastric perforator (DIEP) breast reconstruction between August 2009 and August 2013 underwent preoperative CTA and prospectively entered the study. Patients with postoperative venous congestion were matched with a similar cohort of complication-free patients. Preoperative CTAs were randomized and re-interpreted by a radiologist, blinded to the subsequent clinical outcome. Inter-group comparisons were performed.

RESULTS

Two hundred and forty DIEP flaps were performed in 202 patients over the 4-year study. Venous congestion affected 15 flaps (6.3%). Preoperative CTA showed significantly more atypical venous connections between deep and superficial systems in congested flaps compared to controls (66.7% vs. 8%; P < .0001), with a positive predictive value of 83%. Atypical connections were narrow, tortuous, or incomplete. Patients with congestion-free flaps had more normal connections (80% vs. 26.7%; P < .001) and more cranial perforators (P = .02). Similar CTA findings between groups included perforator size and lateral position, superficial inferior epigastric vein size, crossing of midline, and absent connections (P > .05).

CONCLUSIONS

Preoperative CTA identifies atypical venous connections between deep and superficial systems that increase the risk of postoperative DIEP congestion five-fold. Identifying atypical venous connections maximizes the chances of flap survival and minimizes complications for patients considering DIEP breast reconstruction.

Deep Inferior Epigastric Perforator Versus Free Transverse Rectus Abdominis Myocutaneous Flap: Complications and Resource Utilization

INTRODUCTION

Abdominal based breast reconstruction exists in a continuum from pedicled transverse rectus abdominis myocutaneous (TRAM) flap to deep inferior epigastric perforator (DIEP) free flap. DIEP flap has the advantage of complete rectus abdominis sparing during harvest, thus decreasing donor site morbidity. Aim of this study is to determine whether the surgical advantages of the DIEP flap impact postoperative outcomes versus the free TRAM flap (fTRAM).

METHODS

We reviewed the Nationwide Inpatient Sample database (2010-2011) for all cases of DIEP and fTRAM breast reconstruction. Inclusion criteria were: female sex and patients undergoing DIEP or fTRAM total breast reconstruction. Male sex was excluded from the analysis. We examined demographic characteristics, hospital setting, insurance information, patient income, comorbidities, postoperative complications (including reoperation, hemorrhage, hematoma, seroma, myocardial infarction, pulmonary embolus, wound infection, and flap loss), length of stay, and total charges (TCs). Bivariate and multivariate analyses were performed to identify independent risk factors of increased length of stay and TCs.

RESULTS

Fifteen thousand eight hundred thirty-six cases were identified. Seventy percent were white, 97% were insured, and 83% of patients were treated in an academic teaching hospital setting. No mortalities were recorded. The DIEP cohort was more likely to be obese (P = 0.001). Free TRAM cohort was more likely to suffer pneumonia (P < 0.001; odds ratio [OR], 3.7), wound infection (P = 0.001; OR, 1.7), and wound dehiscence (P < 0.001; OR, 4.3). Type of reconstruction did not appear to affect risk of revision, hemorrhage, hematoma, seroma, or flap loss. Total charges were higher in the DIEP group (P < 0.001). Multivariate analysis demonstrated that fTRAM was an independent risk factor for increased length of stay (P < 0.001; OR, 1.6), and DIEP was an independent risk factor for increased TCs (P < 0.01; OR, 1.5). There was no significant difference in postoperative complications.

CONCLUSIONS

The fTRAM cohort was more likely to develop surgical site complications and have an increased length of stay, but TCs were higher for the DIEP group.

Deep Inferior Epigastric Artery Perforator Flap Breast Reconstruction in Patients With Previous Bariatric Surgery: Is It Safe and Feasible?

BACKGROUND

Obesity is widely recognized as a major health concern and a leading cause of preventable death. The correlation between obesity and breast cancer has been thoroughly described by several authors. Bariatric surgery is often associated with redundant abdominal tissue, often leading patients to consider body-contouring procedures. Autologous tissue breast reconstruction using the deep inferior epigastric artery perforator (DIEP) flap has advantages because it is tissue that is normally discarded during postbariatric body contouring.

METHODS

We conducted a retrospective chart review of 18 DIEP flaps performed by the senior author in 9 patients for breast reconstruction between February 2008 and May 2013. All patients underwent mastectomies. All patients underwent bariatric surgery preceding breast reconstruction. Breast reconstruction was performed immediately in 13 cases and delayed in 5 cases.

RESULTS

Mean age of the study population was 44.6 years (range, 41-57 years). The mean maximum body mass index of the patients was 44 (range, 37.6-52.1), and the mean current body mass index at the time of the reconstruction was 30.7 (range, 24.3-38.1). No intraoperative complications were reported. No fascia or muscle was taken during flap dissection. Mean operative time was 632 minutes (range, from 480 to 750 minutes). Average hospital stay was 4 days. No partial or total flap loss was reported. There were no postoperative hernias or bulges at the abdominal donor site.

CONCLUSIONS

This series represents the largest group of patients undergoing DIEP flap breast reconstruction after bariatric surgery. In the hands of experienced microsurgeons, breast reconstruction with the DIEP flap in postbariatric patients represents a low-risk option with high satisfaction.

Predictors of Reoperations in Deep Inferior Epigastric Perforator Flap Breast Reconstruction

Background:

The deep inferior epigastric perforator (DIEP) procedure is regarded a safe option for autologous breast reconstruction. Reoperations, however, may occur, and there is no consensus in the literature regarding the risk factors. The aim of this study was to identify factors associated with reoperations in DIEP procedure.

Patients and Methods:

A retrospective study of consecutive patients undergoing DIEP breast reconstruction 2007 to 2014 was performed and included a review of 433 medical charts. Surgical outcome was defined as any unanticipated reoperation requiring return to the operating room. Multivariate regression analysis was utilized to identify predictors of reoperation. The following factors were considered: age, body mass index, comorbidity, childbearing history, previous abdominal surgery, adjuvant therapy, reconstruction laterality and timing, flap and perforator characteristics, and number and size of veins.

Results:

In total, 503 free flaps were performed in 433 patients, 363 (83.8%) unilateral and 70 (16.2%) bilateral procedures. Mean age was 51 years; 15.0% were obese; 13.4% had hypertension; 2.3% had diabetes; 42.6% received tamoxifen; 58.8% had preoperative radiotherapy; 45.6% had abdominal scars. Reoperation rate was 15.9% (80/503) and included flap failure, 2.0%; partial flap loss, 1.2%; arterial thrombosis, 2.0%; venous thrombosis, 0.8%; venous congestion, 1.2%; vein kinking, 0.6%. Other complications included bleeding, 2.2%; hematoma, 3.0%; fat necrosis, 2.8%, and infection, 0.2%. Factors negatively associated with reoperation were childbearing history (odds ratio [OR]: 3.18, P = 0.001) and dual venous drainage (OR: 1.91, P = 0.016); however, only childbearing remained significant in the multivariate analyses (OR: 4.56, P = 0.023).

Conclusions:

The history of childbearing was found to be protective against reoperation. Number of venous anastomoses may also affect reoperation incidence, and dual venous drainage could be beneficial in nulliparous patients.

Bilateral Breast Reconstruction with Abdominal Free Flaps: A Single Centre, Single Surgeon Retrospective Review of 55 Consecutive Patients

Breast reconstruction using free tissue transfer is an increasingly utilised oncoplastic procedure. The aim was to review all bilateral breast reconstructions using abdominal free flaps by a single surgeon over an 11-year period (2003–2014). A retrospective review was performed on all patients who underwent bilateral breast reconstruction using abdominal free flaps between 2003 and 2014 by the senior author (DAM). Data analysed included patient demographics, indication for reconstruction, surgical details, and complications. Fifty-five female patients (mean 48.6 years [24–71 years]) had bilateral breast reconstruction. The majority (41, 74.5%) underwent immediate reconstruction and DIEP flaps were utilised on 41 (74.5%) occasions. Major surgical complications occurred in 6 (10.9%) patients, all of which were postoperative vascular compromise of the flap. Failure to salvage the reconstruction occurred on 3 (5.5%) occasions resulting in a total flap failure rate of 2.7%. Obesity (>30 kg/m²) and age > 60 years were shown to have a statistically increased risk of developing postoperative complications (P < 0.05). Our experience demonstrates that abdominal free flaps for bilateral breast reconstruction fares well, with a flap failure rate of 2.7%. Increased body mass index and patient age (>60 years) were associated with higher complication rates.

Delayed Mammoplasty with Silicone Gel Implants following DIEP Flap Breast Reconstruction

The deep inferior epigastric artery perforator (DIEP) flap is a state-of-the-art option for breast reconstruction. However, thin patients with medium- to large-size native breasts are not ideal candidates due to the limited amount of available tissue. We reviewed our experience utilizing the DIEP flap in combination with prosthetic implants.

Donor-Site Hernia Repair in Abdominal Flap Breast Reconstruction: A Population-Based Cohort Study of 7929 Patients

BACKGROUND

The authors investigated hernia repair rates following pedicled transverse rectus abdominis myocutaneous (TRAM), free TRAM, and deep inferior epigastric perforator (DIEP) flap breast reconstruction in English National Health Service hospitals.

METHODS

Women diagnosed with breast cancer who underwent pedicled TRAM, free TRAM, or DIEP flap breast reconstruction procedures in English National Health Service hospitals between April of 2006 and March of 2012 were identified using the Hospital Episode Statistics database. Women who underwent mastectomy without reconstruction acted as controls, and hernia repair rates were calculated for all four groups. Multiple Cox regression was performed to estimate the relative risk of hernia repair among the reconstruction groups, adjusted for age, obesity, previous abdominal surgery, reconstruction year, and bilateral flap harvest.

RESULTS

Between 2006 and 2012, 7929 women had a DIEP or TRAM flap breast reconstruction. The overall hernia repair rate within 3 years was 2.45 percent after abdominal flap breast reconstruction, and 0.28 percent among the 15,679 women who had mastectomy only. Mean time to hernia repair following an abdominal flap harvest was 17.7 months. Compared with DIEP flaps, free and pedicled TRAM flap procedures were associated with adjusted hazard ratios of 1.81 (95 percent CI, 1.24 to 2.64) and 2.89 (95 percent CI, 1.91 to 4.37), respectively. The only independent risk factor for hernia repair was age older than 60 years (p = 0.039).

CONCLUSIONS

Abdominally based autologous breast reconstruction carries a small risk of subsequent donor-site hernia repair. The rates herein can be used to inform patients and to assess quality of care across service providers.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Deep Inferior Epigastric Artery Perforator Flap Breast Reconstruction without Microsurgery Fellowship Training

Background:

Deep inferior epigastric artery perforator (DIEP) flap breast reconstruction requires complex microsurgical skills. Herein, we examine whether DIEP flap breast reconstruction can be performed safely without microsurgical fellowship training.

Methods:

A total of 28 patients and 34 DIEP flaps were included in the study. We reviewed the medical records of patients for donor site and flap-related complications and analyzed the correlation between the complications and preoperative risk factors. We also performed a literature review to compare complication rates in our series with the literature.

Results:

We observed total flap necrosis in 1 patient (2.9%), partial flap necrosis in 5 patients (14.7%), infection in 1 patient (2.9%), hematoma/seroma in 3 patients (8.8%), donor site complications in 5 patients (18.5%), venous occlusion in 4 patients (11.7%), and arterial occlusion in 1 patient (2.9%). We did not observe any correlation between complications and preoperative risk factors. Literature review yielded 18 papers that met our inclusion criteria. Partial flap necrosis rate was significantly higher in our series compared with literature (14.7% vs 1.6%, P = 0.003). Venous complication rate was marginally higher in our series compared with literature (11.7% vs 3.3%, P = 0.057). However, total flap loss rate in our series was comparable with the literature (2.9% vs 2.2%, P = 0.759).

Conclusion:

With proper training during plastic surgery residency, DIEP flap can be performed with acceptable morbidity.

Abdominal perforator vs. muscle sparing flaps for breast reconstruction

Abdominally based free flaps have become the mainstay for women that desire to use their own tissue as a means of breast reconstruction after mastectomy. As the techniques have evolved, significant effort has been invested in finding the best means of minimizing morbidity to the abdominal donor site while ensuring a viable reconstructed breast that is aesthetically pleasing. This manuscript reviews and compares the muscle sparing free transverse rectus abdominis myocutaneous (MsfTRAM), the deep inferior epigastric artery perforator (DIEP), and the superficial inferior epigastric artery (SIEA) flaps, regarding flap success rate, operative times, abdominal donor site morbidity and residual functionality, hospital lengths of stay and associated costs, impact of co-morbid conditions, and resilience after adjuvant radiation treatment.

[The abdominal drop flap]

The skin between the mastectomy scar and the future infra-mammary fold may be managed in different ways in delayed breast reconstruction using a DIEP (deep inferior epigastric perforator). Conserving this skin and positioning the flap skin paddle in the middle of the breast usually highlights skin color disparity because of two visible transition zones. Resection of the entire skin under the scar may be more aesthetic but limits direct closure possibility in case of flap failure. In order to benefit from both aesthetic result and safe surgical method, we propose the abdominal drop flap. The inferior thoracic skin flap is detached from the thoracic wall beyond the future infra-mammary fold, preserved and pushed under the breast.

Racial differences in ischemic complications of pedicled versus free abdominal flaps for breast reconstruction

PURPOSE

This study aims to determine the relationship between race and ischemic complications in women undergoing breast reconstruction with pedicled TRAM (pTRAM) and perforator flaps (DIEP).

PATIENTS AND METHODS

A retrospective, cross-sectional study of women who underwent breast reconstruction utilizing either pTRAM or DIEP flaps from March 1, 2002 to September 1, 2012 was performed. Clinical and demographic variables, including race and ischemic complications (mastectomy flap necrosis, fat necrosis, partial abdominal flap necrosis, vascular compromise requiring reoperation), were examined. Fat necrosis was graded using a previously established scale (grade I = radiologically visible, II = palpable, III = palpable and visible, IV = symptomatic).

RESULTS

Over the 10-year study period, adequate follow-up was available for 138 women (94 Caucasian, 36 African American) who underwent pTRAM or DIEP. Fat necrosis occurred more frequently in the pTRAM group (53.5% vs. 17.4%, P < 0.001). There was no statistically significant difference in partial flap necrosis or mastectomy flap necrosis between the 2 groups. The DIEP group had a higher rate of vascular compromise requiring reoperation (13% vs. 0, P = 0.003). In the pTRAM group, there was a higher rate of fat necrosis (77% vs. 45.6%, P < 0.001) and grade IV fat necrosis in African Americans (42.8% vs. 9.5%, P = 0.005). Rates of other ischemic complications were comparable between the 2 racial groups. In the DIEP group, ischemic complications were comparable between the 2 racial groups. After stratifying by flap type and race, we saw no differences in mastectomy flap necrosis (P = 0.0182).

DISCUSSION

African Americans undergoing pTRAM flap are at higher risk for grade IV fat necrosis but not mastectomy flap necrosis or partial flap necrosis. This may be due to difficulty using physical examination to judge the vascular status of a pedicle flap that is known to undergo significant changes in vascular physiology following transfer. Intraoperative assessment of perfusion using new technologies may be useful in these higher risk patients.

Meta-analysis of the safety and factors contributing to complications of MS-TRAM, DIEP, and SIEA flaps for breast reconstruction

BACKGROUND

Muscle-sparing transverse rectus abdominis myocutaneous (MS-TRAM), deep inferior epigastric perforator (DIEP), and superficial inferior epigastric artery (SIEA) flaps have been increasingly adopted for breast reconstruction. However, their safety, patient satisfaction with them, and factors contributing to complications are not well understood.

METHODS

PubMed, MEDLINE, EMBASE, and The Cochrane Library were searched to identify eligible studies for inclusion in our analysis. The complication rates of and patient satisfaction rates with the flaps were measured as the outcome, and factors contributing to complications and patient satisfaction were also studied. The data were extracted, and pooled relative risks (RRs) and 95 % confidence intervals (CIs) were calculated.

RESULTS

Thirteen studies involving 1,843 patients met the inclusion criteria. The results of the meta-analysis showed that patients with MS-TRAM had a higher rate of abdominal hernias (RR 2.354, 95 % CI 1.154-4.802, P = 0.019) and a lower rate of fat necrosis (RR 0.502, 95 % CI 0.347-0.727, P = 0.000) than patients with DIEP. In addition, there was no significant difference between MS-TRAM and DIEP with respect to other complications (P > 0.05), between MS-TRAM and DIEP with respect to patient satisfaction (P = 0.923), and between DIEP and SIEA with respect to complication rates (P = 0.377). The complication rates of MS-TRAM, DIEP, and SIEA were 25.6, 27.9, and 26.7 %, respectively. Diabetes mellitus (P = 0.078) influenced the complication rate of MS-TRAM, and obesity (P = 0.086) and diabetes mellitus (P = 0.110) were the potential factors correlated with complications with DIEP flaps.

CONCLUSION

There were no obvious differences in the overall incidence of complications between MS-TRAM and DIEP and between DIEP and SIEA. In addition, the patient satisfaction rates of MS-TRAM and DIEP were similar. However, MS-TRAM showed a higher rate of abdominal hernias and a lower rate of fat necrosis than DIEP. Obesity and diabetes mellitus were potential factors associated with the incidence of complications. Additional multicenter, large-sample-size, randomized controlled trials with long-term follow-up visits are necessary.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Using propensity score analysis to compare major complications between DIEP and free muscle-sparing TRAM flap breast reconstructions

BACKGROUND

Previous studies comparing muscle-sparing transverse rectus abdominis myocutaneous (TRAM) versus deep inferior epigastric artery perforator (DIEP) free flaps have not considered procedure selection bias. Propensity score analysis provides a statistical approach to consider preoperative factors in flap selection, and was used to compare major complications (breast and abdominal) between these microsurgical breast reconstruction (free muscle-sparing TRAM versus DIEP).

METHODS

This study evaluated major breast and abdominal complications in 292 consecutive patients (428 free abdominal flaps). Propensity scores were calculated for patient differences affecting flap selection (DIEP versus free muscle-sparing TRAM). Multivariate logistic models using selected covariates separately analyzed breast and abdominal complications between flap methods.

RESULTS

There were 83 major complications (28 percent): breast, 20 percent; abdomen, 8 percent. Using propensity scores, the adjusted odds of abdominal complications were significantly higher in free muscle-sparing TRAM than in DIEP flaps (OR, 2.73; 95 percent CI, 1.01 to 7.07). With prior chemotherapy, body mass index significantly increased abdominal complications (OR, 1.16; 95 percent CI, 1.01 to 1.34). Using propensity scores, there was no significant association between reconstruction method and breast complications; diabetics had significantly increased breast complications (OR, 4.19; 95 percent CI, 1.14 to 15.98). Previous abdominal operations (OR, 1.77; 95 percent CI, 0.96 to 3.30) and immediate reconstruction (OR, 1.86; 95 percent CI, 0.94 to 3.71) approached significance.

CONCLUSIONS

Propensity score analysis indicated significantly higher abdominal complications in free muscle-sparing TRAM compared with DIEP flaps. This study highlights the importance of separately evaluating recipient breast and donor abdominal complications and use of propensity scores to minimize procedure selection bias.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Adjuvant chemotherapy increases the prevalence of fat necrosis in immediate free abdominal flap breast reconstruction

BACKGROUND

Fat necrosis is one of the most common complications following free flap breast reconstruction. Although a minor complication, fat necrosis can compromise esthetic results and confuse with cancer recurrence. Perfusion-related factors and post-operative radiotherapy are the known risks. However, the influence of adjuvant chemotherapy on fat necrosis prevalence remains unknown.

METHODS

Our initial experience of 88 consecutive breast reconstructions with free abdominal flaps was reviewed. The prevalence of fat necrosis was recorded and the risk factors were analyzed using univariate and multivariate logistic regression models.

RESULTS

The overall prevalence of fat necrosis was 36.4% in this series. In a multivariate logistic regression model, adjuvant chemotherapy significantly increased the risk of fat necrosis. The relative risk was 4.762 (95% confidence interval (CI), 1.767-12.831; p = 0.002). There was no evidence of a specific chemotherapeutic agent causing fat necrosis. The first cycle of adjuvant chemotherapy was frequently delivered earlier in patients with fat necrosis than those without fat necrosis, although this tendency was not statistically significant.

CONCLUSIONS

Our initial experience with free flap breast reconstruction seems to suggest that chemotherapy may increase the risk of fat necrosis following immediate breast reconstruction. Patients should be fully informed, and the initiation of post-operative chemotherapy may be adjusted accordingly.

The impact of perforator number on deep inferior epigastric perforator flap breast reconstruction

Background

Perforator flaps minimize abdominal site morbidity during autologous breast reconstruction. The purpose of this study was to assess whether the number of perforators harvested influences the overall deep inferior epigastric perforator (DIEP) flap survival and flap-related complications.

Methods

A retrospective review was performed of all DIEP flaps performed at the Hospital of the University of Pennsylvania from 2006 to 2011. The outcomes assessed included flap loss and major complications. We compared flaps by the number of total perforators (1-4) and then carried out a subgroup analysis comparing flaps with one perforator to flaps with multiple perforators. Lastly, we conducted a post-hoc analysis based on body mass index (BMI) categorization.

Results

Three hundred thirty-three patients underwent 395 DIEP flaps. No significant differences were noted in the flap loss rate or the overall complications across perforator groups. However, the subgroup analysis revealed significantly higher rates of fat necrosis in the case of one-perforator flaps than in the case of multiple-perforator flaps (10.2% vs. 3.1%, P=0.009). The post-hoc analysis revealed a significant increase in the flap loss rate with increasing BMI (<30=2.0%, 30-34.9=3.1%, 35-39.9=3.1%, >40=42.9%, P<0.001) in the DIEP flaps, but no increase in fat necrosis.

Conclusions

This study demonstrates that the number of perforators does not impact the rate of flap survival. However, the rate of fat necrosis may be significantly higher in DIEP flaps based on a single perforator. Multiple perforators should be utilized if possible to decrease the risk of fat necrosis.

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.