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Park JW, Kang JM, Yoo K, Woo KJ. Perfusion area versus volume of the DIEP flap: A multivariable analysis of perforator and flap characteristics for estimation of perfusion area and volume. J Plast Reconstr Aesthet Surg 2024; 96:215-222. [PMID: 39096738 DOI: 10.1016/j.bjps.2024.07.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Revised: 06/24/2024] [Accepted: 07/08/2024] [Indexed: 08/05/2024]
Abstract
BACKGROUND The extent of perfusion of a deep inferior epigastric artery perforator (DIEP) flap is a primary concern for surgeons. This study aimed to determine whether the flap area or volume can be estimated using perforator and flap characteristics. METHODS Intraoperative flap perfusion was assessed using indocyanine green angiography in patients who underwent DIEP flap breast reconstruction between November 2018 and February 2023. The area perfused by a single dominant perforator was delineated on the surface of the flap and measured using the ImageJ software. Multiple linear regression analysis was conducted to estimate the 'perfusion ratio,' defined as the perfused area divided by the total flap area. Potential predictor variables included flap size (cm2), flap thickness (mm), perforator diameter (mm), perforator rows (medial/lateral), vertical location of perforator (at or above/below the umbilicus), and perforator eccentricity (vertical distance from upper flap margin to perforator, cm). RESULTS In total, 101 patients were included in this analysis. The mean 'perfusion ratio' was 67.8% ± 11.5%, predicted by perforator diameter (p = 0.022) and vertical location below umbilicus (p < 0.001) with positive correlations and negatively correlated with flap thickness (p = 0.003) in the multivariable analysis. Both perfusion area and weight were predicted by perforator diameter, vertical location of perforator, flap size, and flap thickness (p < 0.001). The coefficient of determination (adjusted R2) for prediction of perfusion weight was higher than that for the perfusion area (75.5% vs. 69.4%). CONCLUSIONS Flap volume, rather than area, is determined by a perforator of a given diameter and location.
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Affiliation(s)
- Jin-Woo Park
- Department of Plastic and Reconstructive Surgery, Ewha Womans University College of Medicine, Mokdong Hospital, Seoul, Republic of Korea
| | - Jung-Min Kang
- Department of Plastic and Reconstructive Surgery, Ewha Womans University College of Medicine, Mokdong Hospital, Seoul, Republic of Korea
| | - Kyungeun Yoo
- Department of Plastic and Reconstructive Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Kyong-Je Woo
- Department of Plastic and Reconstructive Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.
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Kim M, Ali B, Graziano FD, Colvin K, Boe LA, Allen RJ, Nelson JA, Disa J. Analyzing mastectomy and reconstruction weight in immediate autologous breast reconstruction: A preliminary study. J Surg Oncol 2024; 129:1466-1474. [PMID: 38637992 DOI: 10.1002/jso.27647] [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: 02/15/2024] [Revised: 04/01/2024] [Accepted: 04/07/2024] [Indexed: 04/20/2024]
Abstract
BACKGROUND This study aims to explore the ideal breast size by assessing the relationship between mastectomy to free flap weight ratio and complications as well as patient-reported outcomes in autologous breast reconstruction (ABR). METHOD A retrospective review of patients undergoing bilateral immediate ABR with mastectomy and flap weights available was completed. Patients were divided into three groups based on the ratio of mastectomy to flap weights. The patients were grouped as "maintained" if the flap weight was within 10% of the mastectomy weight. Patients with a weight difference greater than 10% were used to declare "downsized" or "upsized." Outcomes included complications and four domains of the BREAST-Q at 1-year postoperatively. RESULTS Three hundred and fifty-nine patients were included in the analysis, of which 112 were downsized, 91 maintained, and 156 upsized, respectively. Presence of complications did not significantly differ among the groups. At 1-year postoperatively, Sexual Well-being significantly differed (p = 0.033). Between preoperative and 1 year, patients who upsized experienced an improvement in Satisfaction with Breasts by 16 points (p < 0.001), while patients who downsized experienced a decline in Physical Well-being of the Chest by 7 points (p = 0.016). Multivariable linear regression model showed that Sexual Well-being was 13 points lower in the downsized cohort than in the maintained cohort (β = -13, 95% confidence interval: -21 to -5.4; p = 0.001). CONCLUSION Although complication rates do not significantly differ between the three cohorts, patients who downsize may have lower Sexual Well-being postoperatively. Surgeons should consider our preliminary findings to counsel patients preoperatively about the predicted breast size and the impact of downsizing on sexual health.
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Affiliation(s)
- Minji Kim
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Barkat Ali
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Francis D Graziano
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Kate Colvin
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Lillian A Boe
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Robert J Allen
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Jonas A Nelson
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Joseph Disa
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
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Saad N, McGill M, Karamitros G, Cromack D, Wang H, Fisher S, Karamanos E. Surface to Perforator Index: Assessing the Importance of the Number of Perforators in Successful Harvesting of the Anterolateral Thigh Flap. J Reconstr Microsurg 2024; 40:392-397. [PMID: 38061389 DOI: 10.1055/s-0043-1776734] [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: 05/08/2024]
Abstract
BACKGROUND The use of perforator flaps has become more popular with improvement of surgical technique, technology, as well as understanding of microvascular anatomy. The selection of well-perfused angiosomes is critical to the successful outcome of patients undergoing free tissue transfer. The number of perforators that are needed is dependent upon the surface area of the flap being harvested; however, there have been no studies to assess the optimal surface area supplied by each perforator. We hypothesized that the smaller the surface area supplied by each perforator correlated with fewer flap-related complications in the harvesting of the anterolateral thigh (ALT) flap. METHODS All ALT flaps harvested from 2015 to 2021 at our institution were retrospectively reviewed. The surface area of the flap harvested was calculated as A = πab, where a is the long radius and b is the short radius of the ellipse. The surface-perforator index (SPI) was calculated for each flap by dividing the surface area of the ALT flap by the number of perforators supplying the flap. Our primary outcomes were flap-related complications that included: partial flap loss, dehiscence, and venous congestion. RESULTS A total of 106 patients were identified. Twenty-four patients (22.6%) developed perforator-related complications. An increasing SPI and SPI to body surface area were strongly associated with development of complications (adjusted odds ratio [95% confidence interval], adjusted p: 1.02 [1.01, 1.03], < 0.001and 1.23 [1.12, 1.42], p < 0.001). An SPI of greater than 150 cm2/perforator was associated with a higher probability of complications (p < 0.001). CONCLUSION Flap-related complications are significantly related to the number of perforators supplying the flap. The smaller the surface area supplied by a single perforator correlates with significantly fewer flap-related complications. SPI is a new index that may be used as a predictive tool to aid in identifying flaps that may be more prone to complications in free tissue transfer.
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Affiliation(s)
- Noah Saad
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Michelle McGill
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Texas Health San Antonio, San Antonio, Texas
| | - Georgios Karamitros
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Ioaninna, Ioaninna, Greece
| | - Douglas Cromack
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Texas Health San Antonio, San Antonio, Texas
| | - Howard Wang
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Texas Health San Antonio, San Antonio, Texas
| | - Samuel Fisher
- University of Southern Illinois School of Medicine, Carbondale, Illinois
| | - Efstathios Karamanos
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Texas Health San Antonio, San Antonio, Texas
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Khalil AA, ElSharkawy OA, Alsharkawy K, Youssif S, Khalil HH. Supra-arcuate free fascial MS-TRAM, a modified technique to reduce donor site morbidity in obese population-comparative study. Microsurgery 2024; 44:e31124. [PMID: 37846651 DOI: 10.1002/micr.31124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Revised: 09/08/2023] [Accepted: 09/28/2023] [Indexed: 10/18/2023]
Abstract
BACKGROUND Abdomen-based free flaps represent the gold standard option in the armamentarium of breast reconstruction. The natural evolution to more preservation with less invasive forms of these flaps has been driven by both patient and surgeon satisfaction. Nevertheless, obese patients are challenging due to the increased risk of compromised flap perfusion and donor site morbidity. This challenge is compounded by the prevalence of obesity worldwide, resulting in more free abdominal flaps being performed for breast reconstruction in obese patients. The authors present the outcomes of a modified supra-arcuate fascial muscle-sparing transverse rectus abdominus myocutaneous (FMS-TRAM) technique compared to standard muscle-sparing transverse rectus abdominus myocutaneous (MS-TRAM) technique to reduce the donor site morbidity while providing a well-vascularized large volume of autologous tissue. METHODS A retrospective comparative data analysis was conducted at two centers: Cairo University Hospitals, Egypt, and University Hospitals Birmingham, United Kingdom. Standard MS-TRAM was performed in 65 patients between 2008 and 2011 (Group 1) versus 275 patients between 2011 and 2020 (Group 2) who underwent FMS-TRAM. The modified technique involved limiting the fascial incision to above or at the level of the arcuate line to preserve the integrity of the anterior rectus sheath caudally. All patients included were of the obese population (BMI≥30 kg/m2 ) and underwent unilateral post-mastectomy reconstruction. Patient demographics, comorbidities, operative details, and outcomes focusing on donor site morbidity and flap complications were recorded and compared between the two groups. RESULTS The median age and BMI for Group 1 were 43 and 32, respectively. While for Group 2, they were 47 and 33, respectively. Flap weight ranged from 560 to 1470 g (Mean 705) for Group 1, while Group 2 ranged from 510 to 1560 (mean 715). The majority (280/340 [82%]) of the patients in both groups received radiotherapy. 7.7% of Group 1 were smokers, while in Group 2 it was 4.7%. The percentage of delayed versus immediate reconstruction in Group 1 was 60%/40%, while in Group 2, it was 43%/56%. The incidence of fat necrosis, partial necrosis, and total necrosis was 7.6%.1.5%, and 3%, respectively, for Group 1 and 8%, 1.4%, and 2.6%, respectively, for Group 2. The two-tailed p-value demonstrated a significant statistical difference (p < 0.00001) in donor site morbidity between both groups, with more bulge 20% (13/65) and hernia 1.5% (2/65) occurrence in Group 1 versus 1.9% (5/275) and 0.7% (2/275) in Group 2 respectively, over a follow-up period ranging from 24 to 60 months (mean 32). CONCLUSION FMS-TRAM flaps are safe, robust, and reliable with less donor site morbidity while maintaining optimal flap perfusion for large volume flaps in obese patients with excellent, durable outcomes. It should be considered a valuable tool in the reconstructive armamentarium of breast reconstruction.
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Affiliation(s)
- Ashraf A Khalil
- Plastic and Reconstructive Surgery Division, General Surgery Department, Faculty of Medicine, Cairo University, Giza, Egypt
| | - Omar A ElSharkawy
- Plastic and Reconstructive Surgery Division, General Surgery Department, Faculty of Medicine, Cairo University, Giza, Egypt
| | - Kareem Alsharkawy
- Plastic and Reconstructive Surgery Department, University Hospitals, Birmingham, UK
| | - Sherif Youssif
- Plastic and Reconstructive Surgery Department, University Hospitals, Birmingham, UK
| | - Haitham H Khalil
- Plastic and Reconstructive Surgery Department, University Hospitals, Birmingham, UK
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
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Cevallos P, Berry C, Lipman KJ, Kubiak CA, Mohan AT, Ayyala HS, Manrique OJ, Nazerali R. Breast reconstruction after mastectomy in patients with obesity: a narrative review. ANNALS OF TRANSLATIONAL MEDICINE 2023; 11:413. [PMID: 38213816 PMCID: PMC10777214 DOI: 10.21037/atm-23-1599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Accepted: 09/01/2023] [Indexed: 01/13/2024]
Abstract
Background and Objective Breast reconstruction in patients with obesity presents numerous challenges, both in terms of surgical technique and post-operative complication management. As breast reconstruction techniques continue to evolve, the armamentarium of reconstructive options for patients with obesity has vastly expanded. Options now include immediate or delayed, implant-based, autologous, or hybrid reconstruction. Determining the optimal breast reconstruction in this complex population requires nuanced and experienced decision-making. Methods A literature search was conducted to identify studies assessing breast reconstruction considerations in patients with obesity. The search was performed on PubMed and was limited to English language studies published between 1990 and 2023. Primary studies, case reports, chart reviews, and qualitative studies were included. Additional articles were identified for inclusion based on a review of references, as well as a web-based search, to identify additional studies that were not captured with the primary search strategy. Key Content and Findings This narrative review article summarizes the current literature available to guide surgeons in breast reconstruction in patients with obesity. Conclusions The advancements in oncologic surgery and breast reconstruction techniques have expanded available surgical options, including immediate or delayed implant-based, autologous, or hybrid breast reconstruction. Each approach has its unique advantages, disadvantages, and surgical considerations. Despite the challenges, patients with obesity can achieve favorable aesthetic outcomes through careful assessment of comorbidities and expectation management.
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Affiliation(s)
- Priscila Cevallos
- Division of Plastic and Reconstructive Surgery, Stanford University, Palo Alto, CA, USA
- Geisel School of Medicine at Dartmouth, Hanover, NH, USA
| | - Charlotte Berry
- Division of Plastic and Reconstructive Surgery, Stanford University, Palo Alto, CA, USA
| | - Kelsey Jordan Lipman
- Division of Plastic and Reconstructive Surgery, Stanford University, Palo Alto, CA, USA
| | - Carrie A. Kubiak
- Division of Plastic and Reconstructive Surgery, Stanford University, Palo Alto, CA, USA
| | - Anita T. Mohan
- Division of Plastic and Reconstructive Surgery, Stanford University, Palo Alto, CA, USA
| | - Haripriya S. Ayyala
- Division of Plastic and Reconstructive Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Oscar J. Manrique
- Division of Plastic and Reconstructive Surgery, University of Rochester Medical Center, Rochester, NY, USA
| | - Rahim Nazerali
- Division of Plastic and Reconstructive Surgery, Stanford University, Palo Alto, CA, USA
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Kanavou T, Mastorakos DP, Mastorakos PD, Faliakou EC, Athanasiou A. Imaging of the Reconstructed Breast. Diagnostics (Basel) 2023; 13:3186. [PMID: 37892007 PMCID: PMC10605380 DOI: 10.3390/diagnostics13203186] [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: 08/17/2023] [Revised: 10/06/2023] [Accepted: 10/07/2023] [Indexed: 10/29/2023] Open
Abstract
The incidence of breast cancer and, therefore, the need for breast reconstruction are expected to increase. The many reconstructive options available and the changing aspects of the field make this a complex area of plastic surgery, requiring knowledge and expertise. Two major types of breast reconstruction can be distinguished: breast implants and autologous flaps. Both present advantages and disadvantages. Autologous fat grafting is also commonly used. MRI is the modality of choice for evaluating breast reconstruction. Knowledge of the type of reconstruction is preferable to provide the maximum amount of pertinent information and avoid false positives. Early complications include seroma, hematoma, and infection. Late complications depend on the type of reconstruction. Implant rupture and implant capsular contracture are frequently encountered. Depending on the implant type, specific MRI signs can be depicted. In the case of myocutaneous flap, fat necrosis, fibrosis, and vascular compromise represent the most common complications. Late cancer recurrence is much less common. Rarely reported late complications include breast-implant-associated large cell anaplastic lymphoma (BIA-ALCL) and, recently described and even rarer, breast-implant-associated squamous cell carcinoma (BIA-SCC). In this review article, the various types of breast reconstruction will be presented, with emphasis on pertinent imaging findings and complications.
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Affiliation(s)
| | - Dimitrios P Mastorakos
- 2nd Breast Surgery Unit, Mitera Hospital, 15123 Athens, Greece
- Athens Breast Clinic, 11527 Athens, Greece
| | | | - Eleni C Faliakou
- 2nd Breast Surgery Unit, Mitera Hospital, 15123 Athens, Greece
- Athens Breast Clinic, 11527 Athens, Greece
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Ahmed Z, Ioannidi L, Ghali S, Hamilton S, Shtarbanov P, Mosahebi A, Nikkhah D. A Single-center Comparison of Unipedicled and Bipedicled Diep Flap Early Outcomes in 98 Patients. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e5089. [PMID: 37361509 PMCID: PMC10289681 DOI: 10.1097/gox.0000000000005089] [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: 03/08/2023] [Accepted: 05/02/2023] [Indexed: 06/28/2023]
Abstract
The deep inferior epigastric perforator (DIEP) flap is the gold standard for autologous breast reconstruction. One or two pedicles may be used. Our study is the first to compare unipedicled and bipedicled DIEP flaps on donor and recipient site outcomes in the same patient cohort. Methods This is a retrospective cohort study comparing DIEP flap outcomes between 2019 and 2022. Results There were 98 patients, categorized differently for recipient or donor site. The recipient groups were unilateral unipedicled (N = 52), bilateral unipedicled (N = 15), and unilateral bipedicled (N = 31), and donor site groups were unipedicled (N = 52) and bipedicled (N = 46, including bilateral unipedicled and unilateral bipedicled). Bipedicled DIEP flaps had 1.15 times greater odds of donor site complication (95% CI, 0.52-2.55). Adjusting for operative time that was longer in bipedicled DIEP flaps (P < 0.001), odds ratio decreased, and there was a lower probability of donor site complication for bipedicled flaps (OR, 0.84; 95% CI, 0.31-2.29). Odds of recipient area complication was not significantly different between groups. Unilateral unipedicled DIEP flaps had significantly higher rates of revisional elective surgery than unilateral bipedicled DIEP flaps (40.4% versus 12.9%; P = 0.029). Conclusions We demonstrate no significant difference in donor site morbidity between unipedicled and bipedicled DIEP flaps. Bipedicled DIEP flaps do have slightly higher rates of donor site morbidity, which can be partly explained by longer operative times. There is no significant difference in recipient site complications, and bipedicled DIEP flaps can reduce rates of further elective surgery.
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Affiliation(s)
- Zahra Ahmed
- From the Division of Surgery and Interventional Sciences, University College London, London, United Kingdom
| | - Lydia Ioannidi
- Department of Plastic and Reconstructive Surgery, Royal Free London NHS Foundation Trust, London, United Kingdom
| | - Shadi Ghali
- Department of Plastic and Reconstructive Surgery, Royal Free London NHS Foundation Trust, London, United Kingdom
| | - Stephen Hamilton
- Department of Plastic and Reconstructive Surgery, Royal Free London NHS Foundation Trust, London, United Kingdom
| | - Petko Shtarbanov
- Division of Surgery and Interventional Sciences, University College London, London, United Kingdom
| | - Afshin Mosahebi
- Department of Plastic and Reconstructive Surgery, Royal Free London NHS Foundation Trust, London, United Kingdom
- Division of Surgery and Interventional Sciences, University College London, London, United Kingdom
| | - Dariush Nikkhah
- Department of Plastic and Reconstructive Surgery, Royal Free London NHS Foundation Trust, London, United Kingdom
- Division of Surgery and Interventional Sciences, University College London, London, United Kingdom
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Yin SC, Liu YH, Shi C, Qiao QH, Xu ZF, Feng CJ. Comparison of outcomes between single- and multiple-perforator-based free perforator flaps: A systematic review and meta-analysis. Microsurgery 2023; 43:185-195. [PMID: 36086933 DOI: 10.1002/micr.30955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 06/29/2022] [Accepted: 08/05/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND Perforator-based free perforator flaps have become an important tool for the reconstruction of tissue defects. The effect of the number of perforators on the outcomes of perforator flaps has been widely debated. This study aimed to compare the outcomes of single- and multiple-perforator-based free perforator flaps in free-flap reconstruction. METHODS We searched PubMed, Web of Science, EMBASE, Chinese BioMedical Literature Database (CBM), Cochrane Library, and clinicaltrials.gov between January 2000 and June 2021 to identify studies that reported data on the outcomes of free perforator flaps. Two authors individually extracted data and performed quality assessment. Outcomes, including partial flap loss, total loss, fat necrosis, arterial insufficiency, venous insufficiency, hemorrhage and hematoma, wound dehiscence at recipient sites and donor site complications, were evaluated. RESULTS Thirty-two studies with 2498 flaps were included in our analysis. No significant difference was found in the rates of partial loss and arterial insufficiency of flaps, hemorrhage and hematoma, wound dehiscence at recipient sites and donor site complications. However, the multiple-perforator group showed significantly lower rates of total loss (relative risk [RR] = 1.08, 95% confidence interval [CI]: 0.78-1.79, p = .754), fat necrosis (RR = 1.79, 95% [CI]: 1.36-2.36, p = .000) and venous insufficiency (RR = 1.72, 95% CI: 1.07-2.79, p = .026) than the single-perforator group. CONCLUSION The rates of total loss, fat necrosis and venous insufficiency in the multiple-perforator group were lower than those in the single-perforator group. Hence, we recommend that multiple perforators be included in the free perforator flap when appropriate, to yield better clinical outcomes in reconstruction.
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Affiliation(s)
- Shou-Cheng Yin
- Department of Oral and Maxillofacial Surgery, School of Stomatology, China Medical University, Shenyang, Liaoning, China
| | - Yi-Hao Liu
- Department of Oral and Maxillofacial Surgery, School of Stomatology, China Medical University, Shenyang, Liaoning, China
| | - Chao Shi
- Department of Day Surgery Ward, The First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China
| | - Qi-Hui Qiao
- Department of Oral and Maxillofacial Surgery, School of Stomatology, China Medical University, Shenyang, Liaoning, China
| | - Zhong-Fei Xu
- Department of Oral and Maxillofacial Surgery, School of Stomatology, China Medical University, Shenyang, Liaoning, China
| | - Cui-Juan Feng
- Department of Orthodontics, School of Stomatology, China Medical University, Shenyang, Liaoning, China
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9
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Aravind P, Colakoglu S, Bhoopalam M, Ibrahim A, Mathes D, Kaoutzanis C, Mureau M, Reddy S. Perforator Characteristics and Impact on Postoperative Outcomes in DIEP Flap Breast Reconstruction: A Systematic Review and Meta-Analysis. J Reconstr Microsurg 2023; 39:138-147. [PMID: 35714621 DOI: 10.1055/s-0042-1750124] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND High-quality evidence on perforator selection in deep inferior epigastric perforator (DIEP) flap harvesting is lacking, making preoperative planning and choice of perforators "surgeon-specific." This lack of consensus is a subject of continuous debate among microsurgeons. We aimed to systematically review perforator characteristics and their impact on DIEP flap breast reconstruction outcomes. METHODS We conducted a systematic review and meta-analysis across six databases: ClinicalTrials.gov, Cochrane Library, Medline, Ovid Embase, PubMed, and Web of Science for all studies on DIEP flap breast reconstruction focused on perforator characteristics-caliber, number, and location. The primary goal was to analyze the impact of perforator characteristics on partial and/or total flap failure and fat necrosis. Data was analyzed using RevMan V5.3. RESULTS Initial search gave us 2,768 articles of which 17 were included in our review. Pooled analysis did not show any statistically significant correlations between partial and/or total flap failure and perforator number, or perforator location. Sensitivity analysis accounting for heterogeneity across studies showed that, the risk for fat necrosis was significantly higher if single perforators (relative risk [RR] = 2.0, 95% confidence interval [CI] = 1.5-2.6, I 2 = 39%) and medial row perforators (RR = 2.7, 95% CI = 1.8-3.9, I 2 = 0%) were used. CONCLUSION Our findings suggest that a single dominant perforator and medial row perforators may be associated with higher risk of fat necrosis after DIEP flap breast reconstruction. Adopting a standardized perforator selection algorithm may facilitate operative decision making, shorten the learning curve for novice surgeons, and optimize postoperative outcomes by minimizing the burden of major complications. This in turn would help improve patient satisfaction and quality of life.
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Affiliation(s)
- Pathik Aravind
- Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Salih Colakoglu
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Myan Bhoopalam
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Ahmed Ibrahim
- Private Practice at Clevens Face and Body Specialists, Melbourne, Florida
| | - David Mathes
- Division of Plastic and Reconstructive Surgery, University of Colorado - CU Anschutz Medical Campus, Aurora, Colorado
| | - Christodoulos Kaoutzanis
- Division of Plastic and Reconstructive Surgery, University of Colorado - CU Anschutz Medical Campus, Aurora, Colorado
| | - Marc Mureau
- Department of Plastic and Reconstructive Surgery, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Sashank Reddy
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
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10
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Park JW, Lee MK, Woo KJ. Influence of vertical location and spacing of perforators on perfusion in deep inferior epigastric artery perforator flap breast reconstruction: quantitative analysis using indocyanine green angiography. Gland Surg 2022; 11:1851-1863. [PMID: 36654956 PMCID: PMC9840998 DOI: 10.21037/gs-22-371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 10/21/2022] [Indexed: 11/10/2022]
Abstract
Background This study quantitatively assessed perfusion of the deep inferior epigastric artery perforator (DIEP) flap according to vertical location and vertical spacing of perforators during DIEP flap breast reconstruction. Methods In 67 patients who underwent unilateral DIEP flap breast reconstruction between November 2018 and August 2021, flap perfusion was intraoperatively assessed using indocyanine green angiography. Perforators located at or above the umbilicus were defined as vertical zone 1 perforators and those below the umbilicus as vertical zone 2 perforators. Perfusion assessment was conducted in two stages: at stage 1, perfusion solely by single dominant perforators was assessed. At stage 2, the perfusion increment effected by adding a single additional perforator was assessed. Perfused area proportions were compared between patients with dominant perforators in zone 1 versus zone 2. The effect of adding an additional perforator to another vertical zone ("vertical spacing") was also assessed. Results The perfused proportion was significantly higher among vertical zone 2 perforators compared with zone 1 perforators in the evaluation of single dominant perforators (70% vs. 56%; P<0.001). In the evaluation of incremented perfusion by single additional perforators, the perfused proportion was significantly higher in the vertical-spacing group compared to the no-vertical-spacing group (17% vs. 12%; P=0.004). Fat necrosis developed in 4.5 percent of the patients over at least 6 months of follow-up. Conclusions DIEP flap perfusion can be affected by the vertical location of perforators, and flap perfusion can be augmented effectively by vertical spacing of perforators.
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Affiliation(s)
- Jin-Woo Park
- Department of Plastic and Reconstructive Surgery, Ewha Womans University Mokdong Hospital, College of Medicine, Ewha Womans University, Seoul, Republic of Korea
| | - Mi Kyung Lee
- Department of Plastic and Reconstructive Surgery, Ewha Womans University Mokdong Hospital, College of Medicine, Ewha Womans University, Seoul, Republic of Korea
| | - Kyong-Je Woo
- Department of Plastic and Reconstructive Surgery, Ewha Womans University Mokdong Hospital, College of Medicine, Ewha Womans University, Seoul, Republic of Korea
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Haran O, Legarda C, Gofstein D, Adelson D, Singolda R, Madah E, Arad E, Grush AE, Barnea Y. Treatment Algorithm of Postsurgical Fat Necrosis of the Breast—Revisited. Semin Plast Surg 2022; 36:94-100. [DOI: 10.1055/s-0042-1750435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
AbstractFat necrosis is a common complication of breast surgery, with the potential to cause both functional and aesthetic repercussions that can affect patient satisfaction. Although several fat necrosis classification systems have been proposed, fat necrosis management varies widely across institutions, requiring revisiting of existing treatment protocols. We evaluated the postoperative outcomes on 335 breasts following either breast reduction or reconstruction with deep inferior epigastric perforator (DIEP) flaps at our institution between 2016 and 2020, with particular attention to the development of fat necrosis and the need for subsequent surgical intervention. Fat necrosis was diagnosed in 36 (10.74%) breasts, of which 16 (44.4%) were surgically removed and 20 (55.5%) were conservatively managed. Time of fat necrosis diagnosis: early (≤one-month after breast surgery) or late (>1 month) was the only variable associated with surgical intervention. Fat necrosis management should be approached on a case-by-case basis. Whenever possible, conservative management with regular clinical and radiological follow-up, and patient reassurance, should be pursued even for large masses, in the absence of concomitant complications.
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Affiliation(s)
- Oriana Haran
- Department of Plastic and Reconstructive Surgery, Tel-Aviv Sourasky Medical Center, Affiliated with the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Carolina Legarda
- Department of Plastic and Reconstructive Surgery, Tel-Aviv Sourasky Medical Center, Affiliated with the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Dina Gofstein
- Department of Plastic and Reconstructive Surgery, Tel-Aviv Sourasky Medical Center, Affiliated with the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Dana Adelson
- Department of Plastic and Reconstructive Surgery, Tel-Aviv Sourasky Medical Center, Affiliated with the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Roei Singolda
- Department of Plastic and Reconstructive Surgery, Tel-Aviv Sourasky Medical Center, Affiliated with the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Ehab Madah
- Department of Plastic and Reconstructive Surgery, Tel-Aviv Sourasky Medical Center, Affiliated with the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Ehud Arad
- Department of Plastic and Reconstructive Surgery, Tel-Aviv Sourasky Medical Center, Affiliated with the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Andrew E. Grush
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
- Division of Plastic Surgery, Department of Surgery, Texas Children's Hospital, Houston, Texas
| | - Yoav Barnea
- Department of Plastic and Reconstructive Surgery, Tel-Aviv Sourasky Medical Center, Affiliated with the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
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Prevention and Management of Complications of Tissue Flaps. Surg Clin North Am 2021; 101:813-829. [PMID: 34537145 DOI: 10.1016/j.suc.2021.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
In this article, we discuss 4 common free flaps performed in reconstructive surgery: the anterolateral thigh flap, the radial forearm flap, the fibula flap, and the transverse rectus abdominis myocutaneous/deep inferior epigastric perforator flap. Donor and recipient complications for each flap type and strategies on how to prevent and manage such complications are discussed.
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The Intra.Ox Near-Infrared Spectrometer Measures Variations in Flap Oxygenation That Correlate to Flap Necrosis in a Preclinical Rodent Model. Plast Reconstr Surg 2021; 147:1097-1104. [PMID: 33835088 DOI: 10.1097/prs.0000000000007894] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Mastectomy flap necrosis affects 7 to 40 percent of patients undergoing immediate breast reconstruction, with many cases resulting in infection and/or explantation. The Intra.Ox near-infrared spectrometer is a novel device that assesses tissue perfusion by measuring the interactions of light with oxygenated and deoxygenated hemoglobin. This handheld device facilitates serial flap perfusion assessment and may objectively identify at-risk tissues and guide evidence-based treatment algorithms. In this preliminary study, we hypothesized that the Intra.Ox spectrometer detects differences in tissue oxygenation that correlate to tissue necrosis. METHODS Dorsal, random-pattern flaps measuring 10 × 3 cm were raised in eight male Sprague-Dawley rats. Intraoperative tissue oxygen saturation was measured using Intra.Ox in 10 standardized locations. On postoperative day 7, the skin flaps were evaluated for full-thickness necrosis. Data were analyzed using the chi-square test and one-way analysis of variance. A receiver operating characteristic curve assessed the accuracy of intraoperative tissue oxygenation in predicting the risk of flap necrosis. RESULTS Tissue oxygen saturation exhibited a strong negative correlation to distance from the flap pedicle (r = -0.798). Oxygen saturation in tissue that developed necrosis averaged 32 percent, compared to 59 percent in tissues that did not (p < 0.001). The area under the receiver operating characteristic curve was 0.969. Post hoc oxygen saturation cutoffs with 100 percent specificity and sensitivity in predicting necrosis were identified at 46 percent and 54 percent, respectively. CONCLUSIONS Intra.Ox detects significant differences in tissue oxygenation saturation that are associated with the risk for flap necrosis. This technology can be used to identify at-risk tissues and represents an avenue for research aimed at preventing flap necrosis.
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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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Validating machine learning approaches for prediction of donor related complication in microsurgical breast reconstruction: a retrospective cohort study. Sci Rep 2021; 11:5615. [PMID: 33692412 PMCID: PMC7946880 DOI: 10.1038/s41598-021-85155-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Accepted: 02/24/2021] [Indexed: 12/02/2022] Open
Abstract
Autologous reconstruction using abdominal flaps remains the most popular method for breast reconstruction worldwide. We aimed to evaluate a prediction model using machine-learning methods and to determine which factors increase abdominal flap donor site complications with logistic regression. We evaluated the predictive ability of different machine learning packages, reviewing a cohort of breast reconstruction patients who underwent abdominal flaps. We analyzed 13 treatment variables for effects on the abdominal donor site complication rates. To overcome data imbalances, random over sampling example (ROSE) method was used. Data were divided into training and testing sets. Prediction accuracy, sensitivity, specificity, and predictive power (AUC) were measured by applying neuralnet, nnet, and RSNNS machine learning packages. A total of 568 patients were analyzed. The supervised learning package that performed the most effective prediction was neuralnet. Factors that significantly affected donor-related complication was size of the fascial defect, history of diabetes, muscle sparing type, and presence or absence of adjuvant chemotherapy. The risk cutoff value for fascial defect was 37.5 cm2. High-risk group complication rates analyzed by statistical method were significant compared to the low-risk group (26% vs 1.7%). These results may help surgeons to achieve better surgical outcomes and reduce postoperative burden.
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Marks H, Bucknor A, Roussakis E, Nowell N, Kamali P, Cascales JP, Kazei D, Lin SJ, Evans CL. A paintable phosphorescent bandage for postoperative tissue oxygen assessment in DIEP flap reconstruction. SCIENCE ADVANCES 2020; 6:eabd1061. [PMID: 33355131 PMCID: PMC11206211 DOI: 10.1126/sciadv.abd1061] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 11/17/2020] [Indexed: 06/12/2023]
Abstract
Flaps are common in plastic surgery to reconstruct large tissue defects in cases such as trauma or cancer. However, most tissue oximeters used for monitoring ischemia in postoperative flaps are bulky, wired devices, which hinder direct flap observation. Here, we present the results of a clinical trial using a previously untried paintable transparent phosphorescent bandage to assess the tissue's partial pressure of oxygen (pO2). Statistical analysis revealed a strong relationship (P < 0.0001) between the rates of change of tissue oxygenation measured by the bandage and blood oxygen saturation (%stO2) readings from a standard-of-care ViOptix near-infrared spectroscopy oximeter. In addition, the oxygen-sensing bandage showed no adverse effects, proved easy handling, and yielded bright images across all skin tones with a digital single-lens reflex (DSLR) camera. This demonstrates the feasibility of using phosphorescent materials to monitor flaps postoperatively and lays the groundwork for future exploration in other tissue oxygen sensing applications.
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Affiliation(s)
- Haley Marks
- Wellman Center for Photomedicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02129, USA
| | - Alexandra Bucknor
- Division of Plastic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA
| | - Emmanuel Roussakis
- Wellman Center for Photomedicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02129, USA
| | - Nicholas Nowell
- Wellman Center for Photomedicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02129, USA
| | - Parisa Kamali
- Division of Plastic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA
| | - Juan Pedro Cascales
- Wellman Center for Photomedicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02129, USA
| | - Darya Kazei
- Division of Plastic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA
| | - Samuel J Lin
- Division of Plastic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA.
| | - Conor L Evans
- Wellman Center for Photomedicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02129, USA.
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Complications and Patient-reported Outcomes after TRAM and DIEP Flaps: A Systematic Review and Meta-analysis. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2020; 8:e3120. [PMID: 33173667 PMCID: PMC7647662 DOI: 10.1097/gox.0000000000003120] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 07/27/2020] [Indexed: 11/30/2022]
Abstract
Supplemental Digital Content is available in the text. Transverse rectus abdominis myocutaneous (TRAM) and deep inferior epigastric artery perforator (DIEP) flaps are the most common abdominally based breast reconstruction procedures. Each technique has its advantages and disadvantages; however, how morbidity relates to satisfaction is not well-understood. Our aim was to compare complications and patient-reported outcomes following pedicled TRAM (pTRAM), free TRAM (fTRAM), and DIEP flaps to guide flap selection.
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Intraoperative Assessment of DIEP Flap Breast Reconstruction Using Indocyanine Green Angiography: Reduction of Fat Necrosis, Resection Volumes, and Postoperative Surveillance. Plast Reconstr Surg 2020; 146:1e-10e. [DOI: 10.1097/prs.0000000000006888] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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19
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Intraoperative Laser-Assisted Indocyanine Green Imaging Can Reduce the Rate of Fat Necrosis in Microsurgical Breast Reconstruction. Plast Reconstr Surg 2020; 145:507e-513e. [DOI: 10.1097/prs.0000000000006547] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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21
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Wang KC, Tsai CC, Chang CH, Tseng WL, Hung KS, Chang TY, Chen SH, Lee YC. Comparison of flap outcomes between single- and multiple-perforator-based free anterolateral thigh flap in head and neck reconstruction. Microsurgery 2018; 39:150-155. [DOI: 10.1002/micr.30378] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Revised: 07/25/2018] [Accepted: 08/28/2018] [Indexed: 11/09/2022]
Affiliation(s)
- Kuan-Chih Wang
- Division of Plastic and Reconstructive Surgery, Department of Surgery; National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University; Tainan Taiwan
| | - Chia-Chin Tsai
- Division of Plastic and Reconstructive Surgery, Department of Surgery; National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University; Tainan Taiwan
| | - Chih-Hao Chang
- Division of Plastic and Reconstructive Surgery, Department of Surgery; National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University; Tainan Taiwan
| | - Wan-Ling Tseng
- Division of Plastic and Reconstructive Surgery, Department of Surgery; National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University; Tainan Taiwan
| | - Kuo-Shu Hung
- Division of Plastic and Reconstructive Surgery, Department of Surgery; National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University; Tainan Taiwan
| | - Tzu-Yen Chang
- Division of Plastic and Reconstructive Surgery, Department of Surgery; National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University; Tainan Taiwan
| | - Szu-Han Chen
- Division of Plastic and Reconstructive Surgery, Department of Surgery; National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University; Tainan Taiwan
| | - Yao-Chou Lee
- Division of Plastic and Reconstructive Surgery, Department of Surgery; National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University; Tainan Taiwan
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23
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Rose JF, Zavlin D, Garrett AE, Chegireddy V, Ellsworth WA. Evaluation of the single medial circummuscular perforator DIEP flap: Outcomes and comparison to traditional transmuscular single perforator flap. Microsurgery 2017; 38:479-488. [PMID: 29193255 DOI: 10.1002/micr.30273] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Revised: 10/10/2017] [Accepted: 11/10/2017] [Indexed: 11/10/2022]
Abstract
INTRODUCTION Successful breast reconstruction using deep inferior epigastric perforator (DIEP) flaps depends on optimal perforator choice. Circummuscular wraparound medial perforators allow for no rectus dissection and minimal fascial incisions, often presenting as an ideal option. The aim of our study is to evaluate outcomes of the single medial wraparound perforator flap in comparison to more traditional transmuscular single-perforator DIEP flaps. PATIENTS AND METHODS A retrospective chart review was conducted of all DIEP flaps performed by the senior author from 2011 to 2016, yielding 269 flaps on 157 patients. For this study, we included all patients who underwent reconstruction of the breast(s) and possessed circummuscular perforators arising from the DIE vessels. A control group consisted of all consecutive patients with transmuscular one-perforator DIEP flaps. Patient details and their postoperative outcomes were collected. RESULTS In our study, eight patients (5.1%) were of the medial wraparound variety. Sixteen control patients (10.2%) with similar comorbidities had flaps that were of the more traditional single perforator transmuscular variety. There was a slight trend toward decreased operative time in the medial wraparound group, however, it was not found to be statistically significant (536 ± 81 vs. 572 ± 84 min, P = .377). Complication profiles were similar between groups (25.0 vs. 18.8%, P = .722), with no increased rates of fat necrosis in the wraparound cohort. CONCLUSION Based on our findings, using a medial wraparound perforator is a safe and reliable option when compared with a single transmuscular perforator DIEP flap. Choosing the wraparound perforator may show benefit as it eliminates muscular dissection and nerve damage, and tends to minimize fascial incision length.
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Affiliation(s)
- Jessica F Rose
- Institute for Reconstructive Surgery, Houston Methodist Hospital, Weill Cornell Medicine, Houston, Texas
| | - Dmitry Zavlin
- Institute for Reconstructive Surgery, Houston Methodist Hospital, Weill Cornell Medicine, Houston, Texas
| | - Amanda E Garrett
- Institute for Reconstructive Surgery, Houston Methodist Hospital, Weill Cornell Medicine, Houston, Texas
| | - Vishwanath Chegireddy
- Institute for Reconstructive Surgery, Houston Methodist Hospital, Weill Cornell Medicine, Houston, Texas
| | - Warren A Ellsworth
- Institute for Reconstructive Surgery, Houston Methodist Hospital, Weill Cornell Medicine, Houston, Texas
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Techniques and Perforator Selection in Single, Dominant DIEP Flap Breast Reconstruction: Algorithmic Approach to Maximize Efficiency and Safety. Plast Reconstr Surg 2017; 138:790e-803e. [PMID: 27782983 DOI: 10.1097/prs.0000000000002716] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Perforator selection is critical to deep inferior epigastric perforator (DIEP) flap harvest. Commitment to a single perforator has the potential benefit of a simpler dissection, but may increase fat necrosis or perfusion-related complications compared with multiple perforator harvest. METHODS A 3-year retrospective study was carried out of all patients who underwent DIEP flap breast reconstruction performed by the senior author (M.S.-C). Data were collected on patient demographics and surgical outcomes. RESULTS One hundred eighty-three flaps were performed (105 patients) over 3 years. One hundred fifty-six bilateral (78 patients) and 24 unilateral flaps were included in the final study. Mean age was 47.8 ± 8.4 years and mean body mass index was 29.1 ± 5.3 kg/m. Seventy-five percent of flaps were based on single dominant perforators. Single perforators were used in 33.3 percent of flaps weighing over 1000 g, 80 and 74 percent of flaps weighing 500 to 1000 g and less than 500 g, respectively (p = 0.01). There were no differences in overall complications between single- versus multiple-perforator DIEP flaps. Neither body mass index nor flap weight posed additional risk to overall complications. Conversion to a muscle-sparing flap was 9.4 percent. CONCLUSIONS The authors present an algorithm for perforator selection, stepwise approach to flap harvest, and considerations for intraoperative decision-making in DIEP flap reconstruction. Single-dominant perforator flaps can be safely performed, but inclusion of the largest perforator is critical to flap perfusion. Additional perforators must be weighed against the associated tradeoff with donor-site morbidity. The threshold for conversion to a muscle-sparing flap is reduced with increased clinical experience. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
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Volumetric Planning Using Computed Tomographic Angiography Improves Clinical Outcomes in DIEP Flap Breast Reconstruction. Plast Reconstr Surg 2016; 137:771e-780e. [PMID: 27119938 DOI: 10.1097/prs.0000000000002045] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The present study evaluated outcomes of deep inferior epigastric perforator (DIEP) flap breast reconstruction using volumetric planning-which is preoperative planning based on volumetric data of the breast and flap estimated from computed tomographic angiography. METHODS A prospective review of three patient cohorts undergoing DIEP flap breast reconstruction from June of 2009 to February of 2015 was performed. Cohort 1 comprised 48 cases in which no volumetric planning was used. Cohort 2 included the next 101 consecutive cases undergoing breast reconstruction according to an algorithm based on volumetric planning. Cohort 3 consisted of the next 109 consecutive cases using a modified algorithm. The inset rate (weight ratio of the inset flap to harvested flap) was estimated during volumetric planning, and specific surgical strategies, such as incorporating multiple perforators, conducting venous augmentation (cohort 2), or harvesting bipedicled flaps (cohort 3), were used with reference to it. Rates of perfusion-related complications were compared. RESULTS All but one flap survived completely. Fat necrosis occurred in 9.7 percent. Overall, the perfusion-related complication rate was 22.9 percent of cohort 1, 10.9 percent in cohort 2, and 5.6 percent in cohort 3 (p = 0.006). The fat necrosis rates were 19.1, 9.9, and 5.6 percent in cohorts 1, 2, and 3, respectively (p = 0.032). A multivariate analysis demonstrated that volumetric planning had independent benefits for preventing perfusion-related complications (p = 0.003). CONCLUSION The authors' results suggest that volumetric planning can facilitate elaborate planning and reduce perfusion-related complications, enabling reliable breast reconstruction using DIEP flaps. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
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27
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The Transverse Musculocutaneous Gracilis Free Flap: Virtual Animation-Assisted Dissection and Application in Breast Reconstruction. Plast Reconstr Surg 2016; 137:1384-1387. [PMID: 27119913 DOI: 10.1097/prs.0000000000002067] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The transverse musculocutaneous gracilis free flap is a valuable choice for autologous tissue, unilateral or bilateral breast reconstruction. This procedure is an excellent and customized option for immediate or delayed breast reconstruction in patients with small to moderate size breasts. Few descriptions of flap dissection and breast mound shaping are available. In this first educational video, the authors report the original dissection of the transverse musculocutaneous gracilis free flap used for breast reconstruction. Virtual animations insist on surgical key points and relevant details of the harvesting of the flap.
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[Benefit of simultaneous contralateral breast symmetry procedure with unilateral breast reconstruction using DIEP flaps. About 33 cases]. ANN CHIR PLAST ESTH 2015; 60:472-7. [PMID: 26456280 DOI: 10.1016/j.anplas.2015.09.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2015] [Accepted: 09/07/2015] [Indexed: 11/20/2022]
Abstract
BACKGROUND After unilateral breast reconstruction, a procedure on the contralateral breast is often needed to achieve symmetry. Here, we present a single surgeon's experience with performing contralateral symmetry procedures simultaneously with DIEP flap. METHODS We evaluated 33 consecutive patients (mean age, 52.1 years) who underwent DIEP flap unilateral breast reconstruction and a simultaneous contralateral breast procedure performed and 2 patients with delayed controlateral symmetry procedures. A single-stage breast cancer reconstruction is successful if after the original reconstruction no correction for revision of breast mound, or contralateral breast procedures are performed, under general anesthetic, to complete the reconstruction. RESULTS In 24 patients (73%), breast reconstruction was completed after a single stage with one general anesthetic, and in 8 patients (24%), revisions were performed with two general anesthetic (7 patients) and three general anesthetic in one case. Reconstructions requiring more than one general anesthetic were due to 4 of 39 (10%) postoperative complications. Mean operating time was 485 minutes. CONCLUSIONS For patients who need contralateral reduction mammoplasty or mastopexy for symmetry, performing these procedures and breast reconstruction simultaneously facilitates single-stage breast reconstruction in most patients.
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Mastectomy Weight and Tissue Expander Volume Predict Necrosis and Increased Costs Associated with Breast Reconstruction. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2015; 3:e450. [PMID: 26301139 PMCID: PMC4527624 DOI: 10.1097/gox.0000000000000408] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2014] [Accepted: 05/04/2015] [Indexed: 12/26/2022]
Abstract
Introduction: Impaired vascular perfusion in tissue expander (TE) breast reconstruction leads to mastectomy skin necrosis. We investigated factors and costs associated with skin necrosis in postmastectomy breast reconstruction. Methods: Retrospective review of 169 women with immediate TE placement following mastectomy between May 1, 2009 and May 31, 2013 was performed. Patient demographics, comorbidities, intraoperative, and postoperative outcomes were collected. Logistic regression analysis on individual variables was performed to determine the effects of tissue expander fill volume and mastectomy specimen weight on skin necrosis. Billing data was obtained to determine the financial burden associated with necrosis. Results: This study included 253 breast reconstructions with immediate TE placement from 169 women. Skin necrosis occurred in 20 flaps for 15 patients (8.9%). Patients with hypertension had 8 times higher odds of skin necrosis [odd ratio (OR), 8.10, P < 0.001]. Patients with TE intraoperative fill volumes >300 cm3 had 10 times higher odds of skin necrosis (OR, 10.66, P =0.010). Volumes >400 cm3 had 15 times higher odds of skin necrosis (OR, 15.56, P = 0.002). Mastectomy specimen weight was correlated with skin necrosis. Specimens >500 g had 10 times higher odds of necrosis and specimens >1000 g had 18 times higher odds of necrosis (OR, 10.03 and OR, 18.43; P =0.003 and P <0.001, respectively). Mastectomy skin necrosis was associated with a 50% increased inpatient charge. Conclusion: Mastectomy flap necrosis is associated with HTN, larger TE volumes and mastectomy specimen weights, resulting in increased inpatient charges. Conservative TE volumes should be considered for patients with hypertension and larger mastectomy specimens.
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The cost effectiveness of the DIEP flap relative to the muscle-sparing TRAM flap in postmastectomy breast reconstruction. Plast Reconstr Surg 2015; 135:948-958. [PMID: 25811560 DOI: 10.1097/prs.0000000000001125] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The deep inferior epigastric perforator (DIEP) flap has gained notoriety because of its proposed benefit in decreasing donor-site morbidity but has been associated with longer operative times, higher perfusion-related complications, and increased cost relative to muscle-sparing free transverse rectus abdominis myocutaneous (TRAM) flaps. The authors performed the first cost-utility analysis examining the cost effectiveness of DIEP flaps relative to muscle-sparing free TRAM flaps in women who underwent mastectomy. METHODS A comprehensive literature review was conducted using the MED- LINE, Embase, and Cochrane library databases to include studies directly comparing DIEP to muscle-sparing free TRAM flaps in matched patient cohorts. Eight studies were included, examining 740 DIEP flaps and 807 muscle-sparing free TRAM flaps. Costs were derived adopting both societal and third-party payer perspectives. Utilities were derived from a previous cost-utility analysis. Probabilities of clinically relevant complications were combined with cost and utility estimates to fit into a decision tree analysis. RESULTS The overall complication rates were 24.7 percent and 21.8 percent for DIEP and muscle-sparing free TRAM flaps, respectively. The authors' baseline analysis using Medicare reimbursement revealed a cost decrease of $69.42 and a clinical benefit of 0.0035 quality-adjusted life-year when performing DIEP flap surgery relative to muscle-sparing free TRAM flap surgery, yielding an incremental cost-utility ratio of -$19,834.29. When using societal costs, the incremental cost-utility ratio increased to $87,800. CONCLUSION DIEP flaps are cost effective relative to muscle-sparing free TRAM flaps when patients are carefully selected based on perforator anatomy and surgery is performed by experienced surgeons.
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