The Influence of a Pfannenstiel Scar on Venous Anatomy of the Lower Abdominal Wall and Implications for Deep Inferior Epigastric Artery Perforator Flap Breast Reconstruction

A Systematic Approach to Intraoperative Venous Congestion in the Deep Inferior Epigastric Artery Perforator (DIEAP) Flap

The deep Inferior epigastric artery perforator (DIEAP) flap is currently the gold standard for autologous breast reconstruction. This flap is susceptible to venous congestion, which can result in partial or complete flap loss. Apart from external causes, venous congestion may be caused by the flap's vascular architecture, either due to a dominance of the superficial venous system or due to impaired communication between the superficial and deep venous systems. This inefficient vascular architecture can be detected during surgery, and the venous outflow drainage can be improved through several techniques. We present two case reports of intraoperative venous congestion. In the first case, we performed an intra-flap rerouting, through a venous anastomosis between the superficial and the deep venous systems. In the second case, an extra-flap rerouting was executed, through a venous anastomosis between the superficial venous system and a recipient vein. We present the current institutional approach to DIEAP flap breast reconstruction, incorporating surgical insights for addressing intraoperative venous congestion.

Superficial outside-flap shunt (SOS) is associated with a low incidence of postoperative DIEP flap venous congestion: A single-institution retrospective cross-sectional study

INTRODUCTION

Venous congestion burdens up to 15% of deep inferior epigastric artery perforator (DIEP) flap breast reconstructions. For these cases, venous augmentation by superficial outside shunt (SOS) is associated with 100% success in secondary salvage surgeries. Intraoperative venous augmentation using other techniques yields a 0.3% rate of return to theater due to venous congestion, but there is no evidence assessing the effectiveness of the SOS technique applied preventively. Comparing this preventive approach to data prior to its implementation, we expect to find a reduced number of venous congested flaps with reduced flap losses and revision surgeries.

PATIENTS AND METHODS

This retrospective cross-sectional study involved DIEP flap breast reconstructions performed between 2011 and 2020. The control group included patients receiving additional venous anastomosis as a secondary salvage procedure. The "preventive SOS group" included patients who received preventive SOS during the main surgery. Age, body mass index (BMI), pregnancies, perioperative treatments (neoadjuvant or adjuvant chemo or radiotherapy), follow-up complications (arterial ischemia, venous congestion, hematomas, partial/total flap loss), and revision surgeries (breast debridement, flap remodeling) were recorded and compared.

RESULTS

Within 695 flaps performed, 397 flaps were included in the control group, and 298 flaps were included in the preventive SOS group. The groups were homogeneous for age (p = 0.418), BMI (p = 0.747), and flap weight (p = 0.064). Fifty-one flaps (12.8%) in the control group compared to zero (0.0%) in the preventive SOS group required return to theater (p < 0.001).

CONCLUSIONS

We reported encouraging preliminary results for SOS to prevent DIEP flap venous congestion. These results must be validated prospectively.

Use of the superficial inferior epigastric vein in breast reconstruction with a deep inferior epigastric artery perforator flap

Background

Autologous breast reconstruction is highly regarded in reconstructive surgery after mastectomy. DIEP flap reconstruction represents the gold standard for autologous breast reconstruction. The major advantages of DIEP flap reconstruction are its adequate volume, large vascular caliber and pedicle length. Despite reliable anatomy, there are procedures where the plastic surgeon's creativity is required, not only to shape the new breast, but also to overcome microsurgical challenges. An important tool in these cases is the superficial epigastric vein (SIEV).

Methods

150 DIEP flap procedures performed between 2018 and 2021 were retrospectively evaluated for SIEV use. Intraoperative and postoperative data were analyzed. Rate of anastomosis revision, total and partial flap loss, fat necrosis and donor site complications were evaluated.

Results

In a total of 150 breast reconstructions with a DIEP flap performed in our clinic, the SIEV was used in 5 cases. The indication for using the SIEV was to improve the venous drainage of the flap or as a graft to reconstruct the main artery perforator. Among the 5 cases, no flap loss occurred.

Conclusions

Use of the SIEV is an excellent method to expand the microsurgical options in breast reconstruction with DIEP flap surgery. It provides a safe and reliable procedure to improve venous outflow in cases of inadequate outflow from the deep venous system. The SIEV could also provide a very good option for fast and reliable application as an interposition device in case of arterial complications.

Cutaneous Perfusion Dynamics of the Lower Abdomen in Healthy Normal Weight, Overweight and Obese Women: Methods Development Using Infrared Thermography with Applications for Future Wound Management after Caesarean Section

BACKGROUND

Evidence has shown an association between obesity and an increased risk of wound infection after caesarean section. This study was designed to examine if abdominal subcutaneous adiposity impacts upon cutaneous perfusion dynamics.

METHODS

Mild cool challenge, followed by real-time video thermography, was developed to map the appearance of abdominal 'hot spots'. Correspondence of marked 'spots' with audible Doppler and colour and power Doppler ultrasound was performed.

RESULTS

60 healthy, afebrile, women (20-68 years; BMI 18.5-44 kg/m²) were recruited. Hot spot appearance consistently corresponded with audible Doppler sounds. Colour and power Doppler ultrasound revealed vessels at depths of 3-22 mm. No statistically significant interactions for BMI, abdominal circumference or environmental parameters were observed for hot spot count. The temperature of cold stimulus was significant for effects on spot count, but only for the first minute (p = 0.001). Thereafter, effects on spot numbers were not significant.

CONCLUSIONS

Cutaneous 'perforator' mapping of the abdomen (via hot spot appearance) in healthy women, as a potential and future method for risk of perfusion-dependent wound healing complications, reveals that bedside mapping of skin perfusion is feasible over a short interval. Hot spot number was not influenced by BMI or indicators of central fat distribution (abdominal circumference) indicating variability in an individual's vascular anatomy. This study provides the underpinning methodology for personalised perfusion assessment after incisional surgery which may be a more reliable indicator of potential healing complications than body habitus as is currently the norm.

Evaluation of free DIEP flap complications in the setting of previous gynecological operations

BACKGROUND

Autologous tissue breast reconstruction with free deep inferior epigastric perforator (DIEP) flaps is reliable with reproducible results and very few contraindications. However, previous surgery may compromise the abdominal donor site due to injury to the vascular pedicle. The purpose of the current study is to evaluate the effects of prior abdominal surgery on need for changes to the operative plan, intraoperative complications, and postoperative flap compromise.

PATIENTS AND METHODS

A retrospective review of all patients undergoing breast reconstruction with free tissue transfer from the abdomen was performed.

RESULTS

A total of 733 free abdominal flaps were performed in 478 patients during the study period. Two hundred sixty-two (54.8%) patients had prior abdominal surgery with 24.8% laparoscopic/robotic versus 56.9% open versus 18.3% both, 21.4% general surgery versus 60.7% gynecological versus 17.9% both, and 97.7% elective versus 1.1% emergent versus 1.1% both. There were 15 total flap losses (2.0%) and 2 partial flap losses (0.3%). Intraoperative complications and changes in the operative plan occurred in 13 flaps (1.8%) with 84.6% having prior gynecological surgery (p = .0001).

CONCLUSIONS

Free DIEP flap breast reconstruction is becoming more commonplace with a low risk of complications. Although DIEP flaps are still possible in the setting of prior abdominal surgery, there is a higher risk of damage to the deep inferior epigastric pedicle in patients who have had emergency Cesarean sections or hysterectomy. Conducting a focused history may prepare the reconstructive microsurgeon to address and to avoid potential intraoperative complications.

The effect of previous scar on breast reconstruction using abdominal flap: a retrospective analysis of 122 consecutive cases and a strategy to reduce complication rates

Background

Free abdominal tissue transfer is considered the gold standard for autologous breast reconstruction. However, many plastic surgeons are concerned about the theoretical risk of flap-related or donor-site complications associated with previous abdominal surgery. Also, studies have reported conflicting results in the literature due to difference in surgical strategies used in each study. This study analyzes the effect of prior incision on the complications and risk factors in our institution.

Methods

In this retrospective cohort study, we analyzed a total of 122 patients who had undergone reconstructive surgery between March 2012 and February 2019. To assess the effect of prior incision, we divided all patients into a scar group (n=59) and a control group (n=63). Based on our operative approach, patient demographics and postoperative complications were analyzed.

Results

No significant differences were found between patients in the scar group and the control group in flap-related (13.3% vs. 16.4%, P=0.62) and donor-site complications (31.7% vs. 31.4%, P=0.67). In binary logistic regression modeling, only diabetes mellitus was significantly related with donor-site complications (P=0.030).

Conclusions

This result suggested that previous abdominal scars are no longer a reluctant factor for breast reconstruction using an abdominal flap, when an appropriate flap design was used and the surgical techniques were tailored to each scar. In patients with vertical midline or subcostal scar, it requires careful preoperative planning with CT angiography and attentive follow-up are needed.

The Impact of Prior Abdominal Surgery on Complications of Abdominally Based Autologous Breast Reconstruction: A Systematic Review and Meta-Analysis

BACKGROUND

 Approximately half of all patients presenting for autologous breast reconstruction have abdominal scars from prior surgery, the presence of which is considered by some a relative contraindication for abdominally based reconstruction. This meta-analysis examines the impact of prior abdominal surgery on the complication profile of breast reconstruction with abdominally based free tissue transfer.

METHODS

 Literature search was conducted using PubMed, Scopus, and Web of Science. Included studies examined patients with a history of prior abdominal surgery who then underwent abdominally based free flap breast reconstruction. Prior liposuction patients and those with atypical flap designs were excluded. The Newcastle-Ottawa Scale was used to assess study quality. Flap complications included total and partial flap loss, fat necrosis, infection, and reoperation. Donor-site complications included delayed wound healing, infection, seroma, hematoma, and abdominal wall morbidity (hernia, bulge, laxity). Relative risk and 95% confidence intervals (CIs) between groups were calculated. Forest plots, I ² statistic heterogeneity assessments, and publication bias funnel plots were produced. Publication bias was corrected with a trim-and-fill protocol. Overall effects were assessed by fixed-effects and random-effects models.

RESULTS

 After inclusion and exclusion criteria were applied, 16 articles were included for final review. These included 14 cohort and 2 case-control studies, with 1,656 (46.3%) patients and 2,236 (48.5%) flaps having undergone prior surgery. Meta-analysis showed patients with prior abdominal surgery were significantly more likely to experience donor-site delayed wound healing with a risk ratio of 1.27 (random 95% CI [1.00; 1.61]; I ²= 4) after adjustment for publication bias. No other complications were statistically different between groups.

CONCLUSION

 In patients with a history of prior abdominal surgery, abdominally based free tissue transfer is a safe and reliable option. Abdominal scars may slightly increase the risk of delayed donor-site wound healing, which can aid the surgeon in preoperative counseling.

Effects of pre-existing abdominal scar on postoperative complications after autologous breast reconstruction using abdominal flaps: A systematic review and meta-analysis

BACKGROUND

A previous abdominal scar is generally considered as a challenge for breast reconstruction using abdominal flaps. Since it may interfere with the perfusion of abdominal tissue and weaken the abdominal fascia, many plastic surgeons are concerned about the theoretical risk of postoperative complications. This study aims to assess the effects of previous scar on complications in abdominal flap-based breast reconstruction.

METHODS

This systematic review of the literature was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline using MEDLINE, Ovid, and Cochrane databases in March 2020. All studies comparing the complication rates between patients with previous abdominal scars and control group without a scar were included. However, articles such as case series fewer than 10 patients, letters and animal studies were excluded.

RESULTS

A total of 2109 patients underwent 2792 abdominal flap tissue transfers for breast reconstruction in the 11 studies reviewed. A previous scar increased the risk of overall flap complications (RR 1.12; 95% CI, 0.95-1.32; fixed-effect model, I² = 13%) and donor-site complications (RR 1.35; 95% CI, 1.13-1.62; fixed-effect model, I² = 42%, p > 0.05). In particular, the risk of donor-site wound problem was significantly higher than that in the control group (RR 1.83; 95% CI, 1.35-2.46; fixed-effect model, I² = 19%, p > 0.05).

CONCLUSIONS

This study result showed that the previous scar increased the risk for all types of complications compared with the control group. In patients with a vertical midline scar, it requires careful preoperative planning with CT angiography and attentive follow-up. However, with careful preoperative planning and an appropriate strategy, it is possible to overcome the detrimental effect of previous scar.

LEVEL OF EVIDENCE

I.

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 .

Different Hydraulic Constructs to Optimize the Venous Drainage of DIEP Flaps in Breast Reconstruction: Decisional Algorithm and Review of the Literature

BACKGROUND

 Venous congestion is the most common perfusion-related complication of deep inferior epigastric artery perforator (DIEP) flap. Several hydraulic constructs can be created for venous superdrainage in case of flap venous engorgement or as a preventive measure. These can be classified based on the choice of the draining vein of the flap, either a second deep inferior epigastric vein (DIEV) or a superficial inferior epigastric vein (SIEV), and of the recipient vein, either a vein of the chest or the DIEV.

METHODS

 We conducted a comprehensive systematic literature review in Medline, Scopus, EMBASE, Cochrane Library, and Google Scholar to find publications that reported on venous congestion in DIEP flap. The keywords used were DIEP Flap, breast reconstruction, venous congestion, supercharging, superdrainage, SIEV, and DIEV.

RESULTS

 Based on the studies found in the literature, we developed an algorithm to guide the surgeon's decision when choosing the veins for the superdrainage anastomosis.

CONCLUSION

 Several alternatives for venous anastomosis in superdrainage are available. We propose an algorithm to simplify the choice. The use of the ipsilateral SIEV to be connected to a vein of the chest appears to be advantageous. The anatomical position that allows the easiest anastomosis dictates which chest vein to favor.