Make Your Own Deep Inferior Epigastric Artery Perforator Flap: Perforator Delay Improves Deep Inferior Epigastric Artery Perforator Flap Reliability

Surgical delay in abdominal based flap surgery: a scoping review

Background

The abdominal donor site is the most common flap used for breast reconstruction, with flap necrosis a feared complication. The technique of surgical 'delay' involves the inducing of relative ischemia to promote neovascularisation, amongst other metabolic adaptations, and has been used to augment flap vascularity and reduce this complication. There is significant variability in the manner in which flap surgery and surgical delay may be performed, such as the vessels ligated, the presence and degree of flap elevation, and the decision to harvest muscle with the flap, amongst other factors. A formal review of techniques, however, has not yet been performed, and there is no consensus as to the optimal technique for surgical delay.

Methods

A scoping review of the current literature was undertaken to determine the optimal surgical delay technique in abdominal-based flap surgery. A literature search was conducted across PubMed, Embase, Cochrane, and Medline databases. Data regarding the type of flap surgery, delay techniques, and corresponding clinical outcomes was collected and categorised by technique type.

Results

Nine studies met the inclusion criteria and were included for review. Levels of evidence and rates of complications were compared. The range of surgical delay techniques reported in the literature was described. Surgical delay was found to reduce overall complication rates, and the available data suggests it may be particularly beneficial in high-risk patients.

Conclusions

The current data support delay as a viable method for reducing rates of complications. Further studies and data are required to compare surgical delay techniques and determine the benefit delay may pose to patients with risk factors.

The Delay Procedure in Deep Inferior Epigastric Artery Perforator Flap Breast Reconstruction

BACKGROUND

The delay procedure in deep inferior epigastric artery perforator (DIEP) flap breast reconstruction, in which the reduced-caliber choke vessels play a major role, can provide more well-perfused tissue than a standard DIEP flap. The aim of this study was to review the authors' experience with this technique, evaluate the indications, and analyze the surgical outcomes.

METHODS

A retrospective study was conducted of all consecutive DIEP delay procedures performed between March of 2019 and June of 2021. Patient demographic characteristics, operative details, and complications were registered. Patients had preoperative imaging by magnetic resonance angiography to select dominant perforators. The surgical technique involves a two-stage operation. During the first operation, the flaps were pedicled on a dominant perforator and a lateral skin bridge extending toward the lateral flank and lumbar fat; in a second stage, the flap was harvested and transferred.

RESULTS

A total of 82 extended DIEP delay procedures were performed to reconstruct 154 breasts. The majority were bilateral breast reconstructions (87.8%). The delay procedure was used for 38 primary reconstructions (46.3%) and 32 tertiary reconstructions (39.0%). The primary indication was the need for additional volume (79.3%), followed by extensive abdominal scarring and liposuction. After the first operation, seroma was the most frequently observed complication (7.3%). After the second operation, three total flap losses (1.9%) were observed.

CONCLUSIONS

The delay procedure in DIEP flap breast reconstruction results in the harvest of a good amount of abdominal tissue by adding a preliminary procedure. This technique can convert cases previously considered unsuitable into suitable candidates for abdominal-based breast reconstruction.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Short Fasciotomy-Deep Inferior Epigastric Perforator Flap Harvest for Breast Reconstruction

BACKGROUND

Despite several technical modifications to further reduce donor invasiveness in harvesting deep inferior epigastric perforator (DIEP) flaps, techniques with general applicability and demonstrating clinical benefits are scarce. The present study aimed to introduce a short-fasciotomy technique and evaluate its reliability, efficacy, and applicability by comparison with those of conventional methods.

METHODS

A retrospective study was conducted with 304 consecutive patients who underwent DIEP flap-based breast reconstruction. A total of 180 patients underwent the conventional technique between October of 2015 and December of 2018 (cohort 1), and in 124 patients, the short-fasciotomy technique was implemented between January of 2019 and September of 2021 (cohort 2). In the short-fasciotomy technique, the rectus fascia was incised as much as overlies the intramuscular course of targeted perforators. After intramuscular dissection, pedicle dissection proceeded without additional fasciotomy. Postoperative complications and fasciotomy-saving benefits were compared.

RESULTS

The short-fasciotomy technique was successfully adapted for all patients in cohort 2, regardless of length of intramuscular course and number of harvested perforators, with no case requiring conversion to the conventional technique. The mean fasciotomy incision length in cohort 2 was 6.6 cm, which was significantly shorter than that in cohort 1 (11.1 cm). The mean length of the harvested pedicle in cohort 2 was 12.6 cm. No flap loss occurred in either group. The rate of other perfusion-related complications did not differ between the two groups. The rate of abdominal bulge/hernia was significantly lower in cohort 2.

CONCLUSIONS

The short-fasciotomy technique allows for less invasive DIEP flap harvest regardless of anatomical variability. It provides reliable outcomes with minimal functional donor-site morbidity.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Surgical flap delay to allow primary transabdominal transplantation of extended rectus abdominis myocutaneous flaps in increasingly complex pelvic wound reconstructions

Primary intra- or transabdominal transplantation of an extended rectus abdominis myocutaneous (ERAM) flap may help prevent surgical complications of pelvic resections. Surgical delay of the ERAM flap may help prevent intra-abdominal (partial) flap loss after transplantation in highly complex situations including previous irradiation. We report on the outcome of this approach and the risk-factors associated with an eventful outcome. From 2012 to 2020, 105 delayed ERAM flaps were consecutively applied immediately following extended pelvic resections after chemoradiation or hyperthermic intraperitoneal chemotherapy. We addressed the increased reconstructive demands by designing the flap in line with the 10^th rib and delaying the flap's skin island. All post-operative complications were assessed in light of patient-related or procedure-related potential risk-factors. Major complications occurred in 39 patients. These were correlated with surgery for residual or recurrent malignancy (p < 0.01), with tip necrosis after flap delay (p = 0.02), and with the use of a mesh to close the abdominal donor site (p < 0.01). (Partial) flap loss occurred in 4 cases. We observed a comparably high rate of major complications after ERAM transplantations for increasingly extending indications of perineal-pelvic resections. We consider this to be attributable to poorer patients' conditions and disease processes, rather than to flap viability. Delay of the flap allowed for the use of large and voluminous flaps with comparably little (partial) flap loss.

Main factors determining the use of free MS-TRAM and DIEP flaps and comparing the results of breast reconstruction

This study aimed to compare the results of free MS-TRAM and DIEP-flap based on the volume of the transplant and the unique characteristics of blood flow in the tissues. The study included 83 patients, 42 in the MS-TRAM-flap reconstruction group and 41 in the DIEP-flap breast reconstruction group. In the MS-TRAM-flap group, 35 patients received delayed reconstruction, and 7 received one-stage breast reconstruction, including one case of bilateral transplantation. In the DIEP-flap group, 5 patients received one-stage reconstruction, and 36 received delayed reconstruction. Complications associated with the flap tissue were observed in 7 (16.67%) in the MS-TRAM-flap group and 8 (19.51%) cases in the DIEP-flap group. The total level of fat necrosis in MS-TRAM-flap was 7.14% (p=0.033), and in DIEP-flap, it was 9.75% (p=0.039) (2 patients had a substantial amount of fat necrosis, while 2 patients had a modest amount of focal fat necrosis). The number and diameter of perforators (including veins), as well as the transplant volume, are the primary determinants of whether to use a DIEP- or MS-TRAM-flap. DIEP-flap is preferred if there are 1-2 large artery perforators (≥1 mm) and tissue volume of 700-800 grams, while MS-TRAM-flap is used when the tissue volume is significant (>2/3 of standard TRAM-flap).

Current Applications of Ultrasound Imaging in the Preoperative Planning of DIEP Flaps

Background The deep inferior epigastric artery perforator (DIEP) flap has become the gold standard for autologous breast reconstruction at many institutions. Although the deep inferior epigastric artery displays significant anatomic variability in its intramuscular course, branching pattern and location of perforating vessels, the ability to preoperatively visualize and map relevant vascular anatomy has increased the efficiency, safety and reliability of the DIEP flap. While computed tomography angiography (CTA) is often cited as the preoperative imaging modality of choice for perforator flaps, more recent advances in ultrasound technology have made it an increasingly attractive alternative.

Methods An extensive literature review was performed to identify the most common applications of ultrasound technology in the preoperative planning of DIEP flaps.

Results This review demonstrated that multiple potential uses for ultrasound technology in DIEP flap reconstruction including preoperative perforator mapping, evaluation of the superficial inferior epigastric system and as a potential adjunct in flap delay procedures. Available studies suggest that ultrasound compares favorably to other widely-used imaging modalities for these indications.

Conclusion This article presents an in-depth review of the current applications of ultrasound in the preoperative planning of DIEP flaps and explores some potential areas for future investigation.

Planned and Unplanned Delayed Anterolateral Thigh Flap Phalloplasty

Background:

Pedicled anterolateral thigh (ALT) flap phalloplasty can be limited by inadequate perfusion. Vascular delay increases perfusion, as delay causes blood vessel formation by limiting the blood supply available to a flap before transfer. We hypothesized that delayed ALT flap phalloplasty would decrease rates of partial flap or phallus loss and other postoperative complications when compared with previously reported complication rates of undelayed single-stage ALT phalloplasty in our practice.

Methods:

A retrospective medical record review was performed on all phalloplasty patients in our practice between January 2016 and September 2019. We found those patients who had completed delayed ALT flap phalloplasty with at least 6 months of delay and 12 months of follow-up. For these patients, we recorded postoperative complications, simultaneous surgeries, subsequent surgeries, and demographic characteristics.

Results:

Five female-to-male transsexuals underwent delayed ALT flap phalloplasty (two were unplanned procedures, three were planned). Planned delay: The average time between Stage 1 and Stage 2 was 6.5 months. Complications for the planned delay cohort were as follows: partial loss of the neophallus not requiring repair (33%), urethral stricture requiring surgical repair (33%). Unplanned delay: The average time between Stage 1 and Stage 2 was 9.1 months. The following complication was seen in the unplanned delay cohort: urethral stricture requiring surgical repair (50%).

Conclusions:

Vascular delay of ALT flap phalloplasty is a successful emergency salvage procedure. Planned delay of ALT flaps provided similar results compared with those previously reported by our practice with standard single-stage approach.

Early Experience with External Negative Pressure Delay in Free Anterolateral Thigh Perforator Flap Reconstruction

Negative pressure therapy has been utilized in the treatment of open and closed wounds to increase blood flow and improve wound healing. More recently, external negative pressure has been shown to induce a noninvasive delay phenomenon in animal models by increasing vessel size and density within a planned flap, leading to improvement in flap survival. Although successful in animal models, this new method of delay has not been demonstrated in clinical practice. We present our initial experience with preoperative external negative pressure delay of free anterolateral thigh flaps in upper extremity reconstruction to detail the technique and safety profile of this innovative new technique. External negative pressure delay has the potential to provide results similar to those of traditional surgical delay, while being cost effective, safer, and more convenient for patients. More research is needed to investigate the clinical benefit and cost effectiveness of external negative pressure delay.

Laparoscopy allows the harvest of the DIEP flap with shorter fascial incisions as compared to endoscopic harvest: A single surgeon retrospective cohort study

BACKGROUND

We present a comparative series to utilize minimally invasive endoscopic, total extraperitoneal laparoscopic (TEP-lap), and transabdominal preperitoneal robotic perforator (TAP-RAP) harvest of the deep inferior epigastric (DIE) vessels for autologous breast reconstruction (ABR) to mitigate donor site morbidity. We hypothesized that TEP-lap and TAP-RAP harvests of abdominal-based free flaps are safe techniques associated with decreased fascial incision when compared with the endoscopic harvest.

METHODS

We designed a retrospective cohort series of subjects with newly diagnosed breast cancer who presented for ABR using endoscopic (control), laparoscopic, or robotic assistance between September 2017 and April 2019. The primary outcome variables were flap success (i.e., absence of perioperative flap loss), fascial incision length, and intraoperative complications. Secondary variables included operating time, costs, and postoperative complications within 90 days (arterial thrombosis, venous congestion, bulge/hernia, and operative revision). Exclusion criteria included < 90 days follow-up.

RESULTS

In total 94, 38, and 3 subjects underwent endoscopic, TEP-lap, and TAP-RAP flap harvests. Mean lengths of fascial incisions for the endoscopic and laparoscopic cohorts were 4.5 ± 0.5 cm and 2.0 ± 0.6 cm (p < 0.0001), while incision length depended on the concurrent procedure in the robotic cohort. No subjects required conversion to an open harvest. There were no bleeding complications, intra-abdominal injuries, flap losses, or abdominal bulges/hernias noted in the TEP-lap and TAP-RAP cohorts.

CONCLUSION

Minimally invasive DIEP flap harvest may decrease fascial injury when compared with conventional open harvest. There are significant trade-offs among harvest methods. TEP-lap harvest may better balance the trade-off related to abdominal wall morbidity.

Laparoscopically Assisted DIEP Flap Harvest Minimizes Fascial Incision in Autologous Breast Reconstruction

BACKGROUND

Total extraperitoneal laparoscopically assisted harvest of the deep inferior epigastric vessels permits a decrease in myofascial dissection in deep inferior epigastric artery perforator flap breast reconstruction. The authors present a reliable technique that further decreases donor-site morbidity in autologous breast reconstruction.

METHODS

The authors conducted a retrospective cohort study of female subjects presenting to the senior surgeon (S.K.K.) from March of 2018 to March of 2019 for autologous breast reconstruction after a newly diagnosed breast cancer. The operative technique is summarized as follows: a supraumbilical camera port is placed at the medial edge of the rectus muscle to enter the retrorectus space; the extraperitoneal plane is developed using a balloon dissector and insufflation; two ports are placed through the linea alba below the umbilicus to introduce dissection instruments; the deep inferior epigastric vessels are dissected from the underside of the rectus muscle; muscle branches and the superior epigastric are ligated using a Ligasure; and the deep inferior epigastric pedicle is ligated and the vessels are delivered through a minimal fascial incision. The flap(s) is transferred to the chest for completion of the reconstruction.

RESULTS

Thirty-three subjects totaling 57 flaps were included. All flaps were single-perforator deep inferior epigastric artery perforator flaps. Mean fascial incision length was 2.0 cm. Sixty percent of subjects recovered without narcotics. Mean length of stay was 2.5 days. Flap salvage occurred in one subject after venous congestion. Two pedicle transections occurred during harvest that required perforator-to-pedicle anastomosis.

CONCLUSION

Total extraperitoneal laparoscopically assisted harvest of the deep inferior epigastric pedicle is a reliable method that decreases the donor-site morbidity of autologous breast reconstruction.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.