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Does surgical procedure type impact postoperative pain and recovery in deep inferior epigastric artery perforator flap breast reconstruction? Arch Plast Surg 2020; 47:324-332. [PMID: 32718111 PMCID: PMC7398802 DOI: 10.5999/aps.2019.01417] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Accepted: 04/10/2020] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND The deep inferior epigastric artery perforator (DIEP) flap is the commonest flap used for breast reconstruction after mastectomy. It is performed as a unilateral (based on one [unipedicled] or two [bipedicled] vascular pedicles) or bilateral procedure following unilateral or bilateral mastectomies. No previous studies have comprehensively analyzed analgesia requirements and hospital stay of these three forms of surgical reconstruction. METHODS A 7-year retrospective cohort study (2008-2015) of a single-surgeon's DIEP-patients was conducted. Patient-reported pain scores, patient-controlled morphine requirements and recovery times were compared using non-parametric statistics and multivariable regression. RESULTS The study included 135 participants: unilateral unipedicled (n=84), unilateral bipedicled (n=24) and bilateral unipedicled (n=27). Univariate comparison of the three DIEP types showed a significant difference in 12-hour postoperative morphine requirements (P=0.020); bipedicled unilateral patients used significantly less morphine than unipedicled (unilateral) patients at 12 (P=0.005), 24 (P=0.020), and 48 (P=0.046) hours. Multivariable regression comparing these two groups revealed that both reconstruction type and smoking status were significant predictors for 12-hour postoperative morphine usage (P=0.038 and P=0.049, respectively), but only smoking, remained significant at 24 (P=0.010) and 48 (P=0.010) hours. Bilateral reconstruction patients' mean hospital stay was 2 days longer than either unilateral reconstruction (P<0.001). CONCLUSIONS Although all three forms of DIEP flap breast reconstruction had similar postoperative pain measures, a novel finding of our study was that bipedicled DIEP flap harvest might be associated with lower early postoperative morphine requirements. Bilateral and bipedicled procedures in appropriate patients might therefore be undertaken without significantly increased pain/morbidity compared to unilateral unipedicled reconstructions.
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Steiner D, Horch RE, Ludolph I, Schmitz M, Beier JP, Arkudas A. Interdisciplinary Treatment of Breast Cancer After Mastectomy With Autologous Breast Reconstruction Using Abdominal Free Flaps in a University Teaching Hospital-A Standardized and Safe Procedure. Front Oncol 2020; 10:177. [PMID: 32195171 PMCID: PMC7066123 DOI: 10.3389/fonc.2020.00177] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Accepted: 01/31/2020] [Indexed: 01/30/2023] Open
Abstract
Background: Breast cancer is the most common malignancy in women. The interdisciplinary treatment is based on the histological tumor type, the TNM classification, and the patient's wishes. Following tumor resection and (neo-) adjuvant therapy strategies, breast reconstruction represents the final step in the individual interdisciplinary treatment plan. Although manifold flaps have been described, abdominal free flaps, such as the deep inferior epigastric artery perforator (DIEP) or the muscle-sparing transverse rectus abdominis myocutaneous (ms-TRAM) flap, are the current gold standard for autologous breast reconstruction. This retrospective study focuses on the safety of autologous breast reconstruction upon mastectomy using abdominal free flaps. Methods: From April 2012 until December 2018, 193 women received 217 abdominal free flaps for autologous breast reconstruction at the University Hospital of Erlangen. For perforator mapping, we performed computed tomography angiography (CTA). Venous anastomosis was standardized using a ring pin coupler system, and flap perfusion was assessed with fluorescence angiography. A retrospective analysis was performed based on medical records, the surgery report, and follow-up of outpatient course. Results: In most cases, autologous breast reconstruction was performed as a secondary reconstructive procedure after mastectomy and radiotherapy. In total, 132 ms1-TRAM, 23 ms2-TRAM, and 62 DIEP flaps were performed with 21 major complications (10%) during hospital stay including five free flap losses (2.3%). In all cases of free flap loss, we found an arterial thrombosis as the main cause. In 24 patients a bilateral breast reconstruction was performed without free flap loss. The majority of free flaps (96.7%) did not need additional supercharging or turbocharging to improve venous outflow. Median venous coupler size was 2.5 mm (range, 1.5-3.5 mm). Conclusion: Using CTA, intraoperative fluorescence angiography, titanized hernia meshes for rectus sheath reconstruction, and venous coupler systems, autologous breast reconstruction with DIEP or ms-TRAM free flaps is a safe and standardized procedure in high-volume microsurgery centers.
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Affiliation(s)
- Dominik Steiner
- Department of Plastic and Hand Surgery, University Hospital of Erlangen, Friedrich-Alexander University of Erlangen-Nuernberg, Erlangen, Germany
| | - Raymund E Horch
- Department of Plastic and Hand Surgery, University Hospital of Erlangen, Friedrich-Alexander University of Erlangen-Nuernberg, Erlangen, Germany
| | - Ingo Ludolph
- Department of Plastic and Hand Surgery, University Hospital of Erlangen, Friedrich-Alexander University of Erlangen-Nuernberg, Erlangen, Germany
| | - Marweh Schmitz
- Department of Plastic and Hand Surgery, University Hospital of Erlangen, Friedrich-Alexander University of Erlangen-Nuernberg, Erlangen, Germany
| | - Justus P Beier
- Department of Plastic and Hand Surgery, University Hospital of Erlangen, Friedrich-Alexander University of Erlangen-Nuernberg, Erlangen, Germany.,Department of Plastic Surgery, Hand Surgery, Burn Center, University Hospital RWTH Aachen, Aachen, Germany
| | - Andreas Arkudas
- Department of Plastic and Hand Surgery, University Hospital of Erlangen, Friedrich-Alexander University of Erlangen-Nuernberg, Erlangen, Germany
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Keystone Perforator Island Flap for Postmastectomy Defect Resurfacing in Late-stage Breast Cancer Patients. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2019; 7:e2457. [PMID: 31942283 PMCID: PMC6908361 DOI: 10.1097/gox.0000000000002457] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Accepted: 07/26/2019] [Indexed: 11/25/2022]
Abstract
Late-stage breast cancer usually presents with locally advanced disease, with or without metastasis. The primary tumor is typically large with skin infiltration which affects quality of life. Surgical resection will result in an extensive defect which potentially deteriorates patients’ quality of life if not properly managed. Keystone perforator island flap (KPIF) is a local advancement flap based on multiple perforators which can be a reliable reconstructive method to close an extensive defect.
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Phan R, Rozen WM, Chowdhry M, Fitzgerald O'Connor E, Hunter-Smith DJ, Ramakrishnan VV. Risk factors and timing of postoperative hematomas following microvascular breast reconstruction: A prospective cohort study. Microsurgery 2019; 40:99-103. [PMID: 31124177 DOI: 10.1002/micr.30473] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Revised: 05/06/2019] [Accepted: 05/10/2019] [Indexed: 11/07/2022]
Abstract
BACKGROUND Microvascular free tissue transfer has become the gold standard for breast reconstruction. While safe and reliable, there are operative complications, with hematomas developing under the free flap among the more common. These can compromise flap viability, lead to hemodynamic instability and infection. This study aims to identify predictors of hematomas following free-flap breast reconstruction. METHODS A prospective study was undertaken of patients undergoing autologous free-flap breast reconstruction over a 4-year period. Precise times to hematoma formation, age, arterial and venous anastomosis time, and anastomosis length were recorded and analyzed for association with time to hematoma formation. RESULTS One thousand two hundred twelve flaps were undertaken in 1,070 patients during the period of review. Seventy-one (5.8%) flaps were taken back to theater for hematomas. Immediate reconstruction had a significantly higher hematoma rate compared to delayed reconstruction 7.4% versus 5.2% (p < .001). It is noted that there were two main peaks for time to develop hematomas-less than 4 hr postsurgery and between 12 and 15 hr postsurgery. CONCLUSION Hematomas are a complication, which must be managed with prompt return to theater to ensure flap salvage and patient stabilization. Predictors for hematoma are presented, with hematomas most likely encountered within the first 12 hr of surgery.
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Affiliation(s)
- Robert Phan
- Peninsula Clinical School, Central Clinical School, Monash University, Frankston, Victoria, Australia
| | - Warren M Rozen
- Peninsula Clinical School, Central Clinical School, Monash University, Frankston, Victoria, Australia.,St. Andrews Centre for Plastic Surgery and Burns, Broomfield Hospital, Mid Essex Hospital Services NHS Trust, Chelmsford, Essex, UK
| | - Muhammed Chowdhry
- St. Andrews Centre for Plastic Surgery and Burns, Broomfield Hospital, Mid Essex Hospital Services NHS Trust, Chelmsford, Essex, UK
| | - Edmund Fitzgerald O'Connor
- St. Andrews Centre for Plastic Surgery and Burns, Broomfield Hospital, Mid Essex Hospital Services NHS Trust, Chelmsford, Essex, UK
| | - David J Hunter-Smith
- Peninsula Clinical School, Central Clinical School, Monash University, Frankston, Victoria, Australia
| | - Venkat V Ramakrishnan
- St. Andrews Centre for Plastic Surgery and Burns, Broomfield Hospital, Mid Essex Hospital Services NHS Trust, Chelmsford, Essex, UK
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Cho JM, Lee HC, Lee TJ, Kim EK. Unilateral pedicled transverse rectus abdominis musculocutaneous flap and unilateral free deep inferior epigastric artery perforator flap as a surgical alternative in bilateral autologous breast reconstruction. ARCHIVES OF AESTHETIC PLASTIC SURGERY 2019. [DOI: 10.14730/aaps.2019.25.1.9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Steiner D, Horch RE, Ludolph I, Arkudas A. Successful free flap salvage upon venous congestion in bilateral breast reconstruction using a venous cross-over bypass: A case report. Microsurgery 2019; 40:74-78. [PMID: 30693558 PMCID: PMC7003917 DOI: 10.1002/micr.30423] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Revised: 12/11/2018] [Accepted: 12/27/2018] [Indexed: 11/06/2022]
Abstract
Abdominal free flaps such as the muscle sparing transverse rectus abdominis myocutaneous (ms-TRAM) or deep inferior epigastric artery perforator (DIEP) flap represent the gold standard in autologous breast reconstruction. We describe a salvage procedure during bilateral free flap breast reconstruction due to insufficient venous drainage using a venous cross-over bypass. A 54-year-old woman with a thrombosis of the left subclavian port-system in the medical history was elected for simultaneous bilateral breast reconstruction with ms-TRAM and DIEP flaps. Intraoperatively, a venous congestion of the DIEP flap, which was connected to the left cranial internal mammary vessels, appeared. In the absence of sufficient ipsilateral venous recipient vessels, we performed a salvage procedure requiring a 15 cm small saphenous vein graft and presternal subcutaneous tunneling. The flap vein was anastomosed end-to-end with the contralateral caudal internal mammary vein using a coupler system. The postoperative course was uneventful and both flaps survived. We describe the cross-over venous emergency bypass as a useful tool in unexpected venous thrombosis during bilateral free flap breast reconstruction.
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Affiliation(s)
- Dominik Steiner
- Department of Plastic and Hand Surgery, University Hospital of Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Raymund E Horch
- Department of Plastic and Hand Surgery, University Hospital of Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Ingo Ludolph
- Department of Plastic and Hand Surgery, University Hospital of Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Andreas Arkudas
- Department of Plastic and Hand Surgery, University Hospital of Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Erlangen, Germany
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Zavlin D, Steinberg AJ, Chegireddy V, Spiegel AJ. Two successful cases of DIEP flaps for breast reconstruction in patients with Factor V Leiden. J Surg Case Rep 2018; 2018:rjy231. [PMID: 30206474 PMCID: PMC6126179 DOI: 10.1093/jscr/rjy231] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Revised: 07/28/2018] [Accepted: 08/08/2018] [Indexed: 11/14/2022] Open
Abstract
Factor V Leiden (FVL) is the most common inherited hypercoagulable condition. It is a genetic disorder caused by a missense mutation that prevents inactivation of Factor V in the clotting cascade, leading to overproduction of thrombin and excess clotting. This pathophysiological process is especially unfavorable in patients undergoing free tissue transfer. Many authors have noted a propensity for both venous and arterial thrombosis leading to partial or complete flap loss. To date, there have been no published reports of patients with FVL undergoing deep inferior epigastric perforator flap reconstruction without flap complications. Here, the authors present two cases of successful free tissue transfer for breast reconstruction in patients with diagnosed FVL. The perioperative thromboelastography lab values are evaluated to help guide anticoagulation regimen for these high-risk procedures.
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Affiliation(s)
- Dmitry Zavlin
- Institute for Reconstructive Surgery, Houston Methodist Hospital, Weill Cornell Medicine, Houston, TX, USA
| | - Ashley J Steinberg
- Institute for Reconstructive Surgery, Houston Methodist Hospital, Weill Cornell Medicine, Houston, TX, USA
| | - Vishwanath Chegireddy
- Institute for Reconstructive Surgery, Houston Methodist Hospital, Weill Cornell Medicine, Houston, TX, USA
| | - Aldona J Spiegel
- Institute for Reconstructive Surgery, Houston Methodist Hospital, Weill Cornell Medicine, Houston, TX, USA
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Coady-Fariborzian L, Anstead C, Leyngold M, McGuire J. Assessment of Free Flap Breast Reconstructions. Fed Pract 2017; 34:33-36. [PMID: 30766297 PMCID: PMC6370455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Free flap breast reconstruction may be offered as a treatment option at federal facilities with appropriate patient selection and planning.
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Affiliation(s)
| | - Christy Anstead
- and are surgeons, and is a nurse practitioner, all at Malcom Randall VAMC in Gainesville, Florida
| | - Mark Leyngold
- and are surgeons, and is a nurse practitioner, all at Malcom Randall VAMC in Gainesville, Florida
| | - James McGuire
- and are surgeons, and is a nurse practitioner, all at Malcom Randall VAMC in Gainesville, Florida
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Schaverien MV, Butler CE. Complications in DIEP Flap Breast Reconstruction After Mastectomy for Breast Cancer: A Prospective Cohort Study Comparing Unilateral and Bilateral Reconstructions. Ann Surg Oncol 2017; 24:1451-1453. [DOI: 10.1245/s10434-017-5809-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/29/2023]
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