1
|
Papadopoulos S, Vidovic G, Tio J, Moysiadis T, Lioupis M, Athanasiadis AP, Abdallah A. Fat grafting in breast surgery: a retrospective single-breast centre 6-year experience. Arch Gynecol Obstet 2024:10.1007/s00404-024-07708-7. [PMID: 39235471 DOI: 10.1007/s00404-024-07708-7] [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: 03/05/2024] [Accepted: 08/18/2024] [Indexed: 09/06/2024]
Abstract
PURPOSE In recent years, fat grafting has gained importance as a valuable technique in breast surgery. As a breast center that has embraced this approach, we aimed to investigate the indications and complications of fat grafting. METHODS In this retrospective study, we examined a total of 263 lipofilling treatments on 121 patients. Five groups were identified: the reconstruction group (72.7%), consisting of 24.8% autologous and 38% implant-based reconstructions after cancer, and correction of the tuberous breasts (10.7%). An almost equivalent group (10.7%), consisted of patients treated for cosmetic reasons. Patients after breast-conserving therapy amounted to 16.5%. Twenty patients (16.5%) were treated to alleviate pain. RESULTS No major complications, and no cancer recurrence or metastasis were observed. One case of infection occurred at the injection site (infection rate: 0.38%). ANOVA showed statistically significant results for age (p < 0.001) and mean fat volume (p = 0.001). Posthoc analysis showed that the mean age of the tuberous group (21 years) was significantly smaller compared to all other categories (p < 0.001). Post-hoc analysis for fat volume indicated that the mean value for the cosmetic category (447.08 cc) was significantly greater than that of the breast-conserving and implant reconstruction categories (p = 0.009 and p = 0.030, respectively), while not significantly different from the tuberous and autologous reconstruction categories (p = 0.928 and p = 0.648, respectively). CONCLUSIONS Lipofilling has proven a valuable adjunct in reconstructive and aesthetic breast surgery with a low complication profile. The versatility of this low-cost technique and the low rate of complications make it a powerful asset of modern breast centers.
Collapse
Affiliation(s)
- Sarantos Papadopoulos
- Department of Senology, Evangelische Kliniken Gelsenkirchen, Munckelstrasse 27, 45879, Gelsenkirchen, Germany.
| | - Goran Vidovic
- Private Practice in Senology, Obstetrics and Gynecology, Bochum, Germany
| | - Joke Tio
- Department of Obstetrics and Gynecology, Breast Center, Muenster University, Muenster, Germany
| | - Theodoros Moysiadis
- Department of Computer Science, School of Sciences and Engineering, University of Nicosia, Nicosia, Cyprus
| | - Matteo Lioupis
- Department of Senology, Evangelische Kliniken Gelsenkirchen, Munckelstrasse 27, 45879, Gelsenkirchen, Germany
| | - Apostolos P Athanasiadis
- 3rd Department of Obstetrics and Gynecology, Medical School, Aristotle University Thessaloniki, Thessaloniki, Greece
| | - Abdallah Abdallah
- Department of Senology, Evangelische Kliniken Gelsenkirchen, Munckelstrasse 27, 45879, Gelsenkirchen, Germany
| |
Collapse
|
2
|
Wang CS, Al-Nowaylati AR, Matusko N, Momoh AO, Kung TA. Simultaneous Co-surgeon Deep Inferior Epigastric Perforator (DIEP) Flap Breast Reconstructions: Feasibility and Clinical Outcomes. Ann Surg Oncol 2024; 31:5409-5416. [PMID: 38619709 DOI: 10.1245/s10434-024-15266-0] [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: 08/16/2023] [Accepted: 03/22/2024] [Indexed: 04/16/2024]
Abstract
BACKGROUND A co-surgeon model is known to be favorable in microvascular breast reconstruction, but simultaneous co-surgeon deep inferior epigastric perforator (DIEP) flap cases have not been well-studied. The authors hypothesize that performing two simultaneous co-surgeon bilateral DIEP flap reconstructions results in non-inferior clinical outcomes and may improve patient access to care. METHODS A single-institution, retrospective cohort study was performed utilizing record review to identify all cases of co-surgeon free-flap breast reconstructions over a 38-month period. Patients who underwent simultaneous bilateral DIEP flap breast reconstructions with the same two co-surgeons were identified. The control group consisted of subjects who underwent non-simultaneous reconstruction by the same co-surgeons within the same, preceding, or following month of those in the study group. Primary outcome variables were 90-day postoperative complications, while secondary outcomes were operating time, ischemia time, and length of stay. Descriptive statistics, univariate and multivariable regression analyses were performed. RESULTS Overall, 137 subjects were identified and 64 met the inclusion criteria (n = 28 study, n = 36 control). There were no statistically significant differences between groups in body mass index, radiation, trainee experience, flap perforator number, immediate/delayed reconstruction, or length of stay. There were also no statistically significant differences in complications, including flap loss, anastomosis revision, take-back to the operating room, or re-admission. Operative time was longer in the simultaneous DIEP group (540.5 vs. 443.5 min, p < 0.01), but ischemia time was shorter in the simultaneous group (64.0 vs. 80.5 min, p < 0.01). CONCLUSIONS A simultaneous co-surgeon approach to bilateral DIEP flap reconstruction may improve access to care and does not result in a higher complication rate compared with non-simultaneous bilateral DIEP flaps.
Collapse
Affiliation(s)
- Christine S Wang
- Section of Plastic Surgery, Department of Surgery, Michigan Medicine, University of Michigan Health System, Ann Arbor, MI, USA
| | | | - Niki Matusko
- Department of Surgery, Michigan Medicine, Ann Arbor, MI, USA
| | - Adeyiza O Momoh
- Section of Plastic Surgery, Department of Surgery, Michigan Medicine, University of Michigan Health System, Ann Arbor, MI, USA
| | - Theodore A Kung
- Section of Plastic Surgery, Department of Surgery, Michigan Medicine, University of Michigan Health System, Ann Arbor, MI, USA.
| |
Collapse
|
3
|
Minkhorst K, Castanov V, Li EA, Farrokhi K, Jaszkul KM, AlGhanim K, DeLyzer T, Simpson AM. Alternatives to the Gold Standard: A Systematic Review of Profunda Artery Perforator and Lumbar Artery Perforator Flaps for Breast Reconstruction. Ann Plast Surg 2024; 92:703-710. [PMID: 38768024 DOI: 10.1097/sap.0000000000003916] [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: 05/22/2024]
Abstract
INTRODUCTION Breast reconstruction with the deep inferior epigastric perforator (DIEP) flap is the current gold-standard autologous option. The profunda artery perforator (PAP) and lumbar artery perforator (LAP) flaps have more recently been described as alternatives for patients who are not candidates for a DIEP flap. The aim of this study was to review the survival and complication rates of PAP and LAP flaps, using the DIEP flap as a benchmark. METHODS A literature search was conducted using PubMed, MEDLINE, Embase, BIOSIS, Web of Science, and Cochrane databases. Papers were screened by title and abstract, and full texts reviewed by three independent blinded reviewers. Quality was assessed using MINORS criteria. RESULTS Sixty-three studies were included, for a total of 745 PAP, 62 stacked PAP, 187 LAP, and 23,748 DIEP flap breast reconstructions. The PAP (98.3%) had comparable success rate to DIEP (98.4%), and the stacked PAP (88.7%) and LAP (92.5%) success rate was significantly lower (P < 0.0001). The PAP and LAP groups both had a low incidence of fat necrosis. However, the revision rate for the LAP group was 16.1% whereas the PAP group was 3.3%. Donor site wound dehiscence rate was 2.9 in the LAP group and 9.1% in the PAP group. CONCLUSIONS Profunda artery perforator and DIEP flaps demonstrate very high rates of overall survival. The LAP flap has a lower survival rate. This review highlights the survival and complication rates of these alternative flaps, which may help clinicians in guiding autologous reconstruction technique when a DIEP flap is unavailable.
Collapse
Affiliation(s)
| | - Valera Castanov
- Division of Plastic and Reconstructive Surgery, Western University, London, Ontario, Canada
| | - Erica Ai Li
- From the Schulich School of Medicine, Western University, London
| | - Kaveh Farrokhi
- From the Schulich School of Medicine, Western University, London
| | | | | | | | | |
Collapse
|
4
|
Musmann RJ, Andree C, Munder B, Hagouan M, Janku D, Daniels M, Aufmesser-Freyhardt B, Becker K, Oramary A, Bromba A, Stockhausen N, Wolter A, Fertsch S. Secondary solution for breast reconstruction following total DIEP flap loss: A single-center experience after 3270 DIEP flaps. J Plast Reconstr Aesthet Surg 2024; 92:11-25. [PMID: 38489983 DOI: 10.1016/j.bjps.2024.02.059] [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: 10/10/2023] [Revised: 02/02/2024] [Accepted: 02/22/2024] [Indexed: 03/17/2024]
Abstract
BACKGROUND Total deep inferior epigastric perforator (DIEP) flap failure is a significant concern in autologous breast reconstruction. Literature on secondary reconstruction options following total flap failure is limited. This study outlines the outcomes of patients who underwent reconstruction post-DIEP flap failure at our institution. METHODS We conducted a retrospective analysis of patients receiving autologous breast reconstruction between 2004 and 2021. We aimed to identify causes of total DIEP flap failure, outcomes of revision surgery, and outcomes of secondary breast reconstruction procedures. RESULTS From 2004 to 2021, 3456 free flaps for breast reconstruction were performed, with 3270 being DIEP flaps for 2756 patients. DIEP flap failure was observed in 40 cases (1.22%). Bilateral reconstructions had a higher failure rate (2.31%) than unilateral (0.72%). The primary cause was intraoperative complications during flap harvest (18 cases), followed by insufficient arterial perfusion (seven cases). Other causes included postoperative hematoma (seven cases), venous congestion (six cases), and late-onset fat necrosis (two cases). Post-failure, five patients received a second free flap with three cases of repeated flap failure. Twenty patients received implant-based reconstruction with two cases of reconstruction failure, while seven patients received a pedicled latissimus dorsi (LD) flap reconstructions with no cases of reconstruction failure. Eight patients declined further reconstruction. CONCLUSION A second free flap post-DIEP failure was associated with a high risk of reconstruction failure, suggesting the need for careful patient selection. Implant-based and pedicled LD flap seem to be reliable secondary reconstruction options.
Collapse
Affiliation(s)
- R J Musmann
- Dept. of Plastic and Aesthetic Surgery, Sana Krankenhaus Gerresheim, Gräulinger Straße 120, D-40625 Düsseldorf, Germany.
| | - C Andree
- Dept. of Plastic and Aesthetic Surgery, Sana Krankenhaus Gerresheim, Gräulinger Straße 120, D-40625 Düsseldorf, Germany; Heinrich-Heine-Universität Düsseldorf, Universitätsstraße 1, 40225 Düsseldorf
| | - B Munder
- Dept. of Plastic and Aesthetic Surgery, Sana Krankenhaus Gerresheim, Gräulinger Straße 120, D-40625 Düsseldorf, Germany
| | - M Hagouan
- Dept. of Plastic and Aesthetic Surgery, Sana Krankenhaus Gerresheim, Gräulinger Straße 120, D-40625 Düsseldorf, Germany
| | - D Janku
- Dept. of Plastic and Aesthetic Surgery, Sana Krankenhaus Gerresheim, Gräulinger Straße 120, D-40625 Düsseldorf, Germany
| | - M Daniels
- Dept. of Plastic and Aesthetic Surgery, Sana Krankenhaus Gerresheim, Gräulinger Straße 120, D-40625 Düsseldorf, Germany; Universität Witten-Herdecke, Fakultät für Gesundheit, Alfred-Herrhausen-Straße 45, 58455 Witten, Germany
| | - B Aufmesser-Freyhardt
- Dept. of Plastic and Aesthetic Surgery, Sana Krankenhaus Gerresheim, Gräulinger Straße 120, D-40625 Düsseldorf, Germany
| | - K Becker
- Dept. of Plastic and Aesthetic Surgery, Sana Krankenhaus Gerresheim, Gräulinger Straße 120, D-40625 Düsseldorf, Germany
| | - A Oramary
- Dept. of Plastic and Aesthetic Surgery, Sana Krankenhaus Gerresheim, Gräulinger Straße 120, D-40625 Düsseldorf, Germany
| | - A Bromba
- Dept. of Plastic and Aesthetic Surgery, Sana Krankenhaus Gerresheim, Gräulinger Straße 120, D-40625 Düsseldorf, Germany
| | - N Stockhausen
- Dept. of Plastic and Aesthetic Surgery, Sana Krankenhaus Gerresheim, Gräulinger Straße 120, D-40625 Düsseldorf, Germany
| | - A Wolter
- Dept. of Plastic and Aesthetic Surgery, Sana Krankenhaus Gerresheim, Gräulinger Straße 120, D-40625 Düsseldorf, Germany; Universität Witten-Herdecke, Fakultät für Gesundheit, Alfred-Herrhausen-Straße 45, 58455 Witten, Germany
| | - S Fertsch
- Dept. of Plastic and Aesthetic Surgery, Sana Krankenhaus Gerresheim, Gräulinger Straße 120, D-40625 Düsseldorf, Germany; Universität Witten-Herdecke, Fakultät für Gesundheit, Alfred-Herrhausen-Straße 45, 58455 Witten, Germany
| |
Collapse
|
5
|
Fisher MH, Ohmes LB, Yang JH, Le E, Colakoglu S, French M, Siddikoglu D, Um G, Winocour J, Higdon K, Perdikis G, Inchauste S, Cohen J, Chong T, Kaoutzanis C, Mathes DW. Abdominal donor-site complications following autologous breast reconstruction: A multi-institutional multisurgeon study. J Plast Reconstr Aesthet Surg 2024; 90:88-94. [PMID: 38364673 DOI: 10.1016/j.bjps.2024.01.033] [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: 10/17/2023] [Revised: 12/13/2023] [Accepted: 01/29/2024] [Indexed: 02/18/2024]
Abstract
BACKGROUND The deep inferior epigastric perforator (DIEP) free flap is the gold standard procedure for autologous breast reconstruction. Although breast-related complications have been well described, donor-site complications and contributing patient risk factors are poorly understood. METHODS We examined a multi-institutional, prospectively maintained database of patients undergoing DIEP free flap breast reconstruction between 2015 and 2020. We evaluated patient demographics, operative details, and abdominal donor-site complications. Logistic regression modeling was used to predict donor-site outcomes based on patient characteristics. RESULTS A total of 661 patients were identified who underwent DIEP free flap breast reconstruction across multiple institutions. Using logistic regression modeling, we found that body mass index (BMI) was an independent risk factor for umbilical complications (odds ratio [OR] 1.11, confidence interval [CI] 1.04-1.18, p = 0.001), seroma (OR 1.07, CI 1.01-1.13, p = 0.003), wound dehiscence (OR 1.10, CI 1.06-1.15, p = 0.001), and surgical site infection (OR 1.10, CI 1.05-1.15, p = 0.001) following DIEP free flap breast reconstruction. Further, immediate reconstruction decreases the risk of abdominal bulge formation (OR 0.22, CI 0.108-0.429, p = 0.001). Perforator selection was not associated with abdominal morbidity in our study population. CONCLUSIONS Higher BMI is associated with increased abdominal donor-site complications following DIEP free flap breast reconstruction. Efforts to lower preoperative BMI may help decrease donor-site complications.
Collapse
Affiliation(s)
- Marlie H Fisher
- Department of Plastic and Reconstructive Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Lucas B Ohmes
- Department of Plastic and Reconstructive Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Jerry H Yang
- Department of Plastic and Reconstructive Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Elliot Le
- Department of Plastic and Reconstructive Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Salih Colakoglu
- Department of Plastic and Reconstructive Surgery, Johns Hopkins Medicine, Baltimore, MD, United States
| | - Mackenzie French
- Department of Plastic and Reconstructive Surgery, University of Washington, Seattle, WA, United States
| | - Duygu Siddikoglu
- Department of Biostatistics, Canakkale OnSekiz Mart Faculty of Medicine, Canakkale, Turkey
| | - Grace Um
- Department of Plastic and Reconstructive Surgery, University of Washington, Seattle, WA, United States
| | - Julian Winocour
- Department of Plastic and Reconstructive Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Kent Higdon
- Department of Plastic and Reconstructive Surgery, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Galen Perdikis
- Department of Plastic and Reconstructive Surgery, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Suzanne Inchauste
- Department of Plastic and Reconstructive Surgery, University of Washington, Seattle, WA, United States
| | - Justin Cohen
- Department of Plastic and Reconstructive Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Tae Chong
- Department of Plastic and Reconstructive Surgery, Virginia Commonwealth University, Richmond, VA, United States
| | - Christodoulos Kaoutzanis
- Department of Plastic and Reconstructive Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - David W Mathes
- Department of Plastic and Reconstructive Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, United States.
| |
Collapse
|
6
|
Sacak B, Sakarya AH, Haytaoglu AA, Akdeniz Dogan Z, Ugurlu MU. Do bilateral procedures further increase the complications for autologous breast reconstruction in obese patients? Breast Cancer Res Treat 2023; 202:435-442. [PMID: 37658278 DOI: 10.1007/s10549-023-07082-z] [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: 04/19/2023] [Accepted: 08/10/2023] [Indexed: 09/03/2023]
Abstract
BACKGROUND Obesity is known to be associated with high complication rates. The aim of this study was to evaluate the effect of bilateral procedures on complication rates in obese patients undergoing autologous breast reconstruction with deep inferior epigastric perforator flaps. METHODS Medical records of patients undergoing autologous breast reconstruction between January 2017 and December 2019 were retrospectively reviewed. Patients were divided into two groups according to their body mass index (BMI): Group 1 (BMI > 30) and Group 2 (BMI < 30). Group 1 was further divided into 3 subgroups: Group 1a (bilateral reconstruction), Group 1b (unilateral reconstruction), and Group 1c (unilateral reconstruction and contralateral symmetrization). Outcomes and complication rates were compared between groups. RESULTS Ninety-one patients (with 119 free flaps) were followed up between 6 and 12 months. Length of hospital stay, smoking rates, and age were similar in all groups. Group 1 had significantly more rates of wound dehiscence (p = 0.024), mastectomy skin flap necrosis (p = 0.019), and re-operation (p = 0.033). The operation time was significantly higher in group 1 (p = 0.003). There was no significant difference between group 1 and group 2 in terms of hematoma-seroma formation, flap loss, and pulmonary thromboembolism rates. When obese subgroups were compared, no significant difference was observed in terms of complications. CONCLUSION In our series, microvascular breast reconstruction was associated with more complication rates in obese patients. However, bilateral procedures in the obese patient group did not significantly increase risk of complications as compared to unilateral procedures. By taking appropriate measures bilateral procedures can be performed in obese patients without additional risks.
Collapse
Affiliation(s)
- Bulent Sacak
- Department of Plastic Aesthetic and Reconstructive Surgery, Marmara University School of Medicine, Istanbul, Turkey
| | - Ahmet Hamdi Sakarya
- Department of Plastic Aesthetic and Reconstructive Surgery, Marmara University School of Medicine, Istanbul, Turkey
| | - Adem Atakan Haytaoglu
- Department of Plastic Aesthetic and Reconstructive Surgery, Marmara University School of Medicine, Istanbul, Turkey.
- Marmara University Hospital Pendik Istanbul, Fevzi Cakmak, Muhsin Yazicioglu St. No:10, Istanbul, Turkey.
| | - Zeynep Akdeniz Dogan
- Department of Plastic Aesthetic and Reconstructive Surgery, Marmara University School of Medicine, Istanbul, Turkey
| | - Mustafa Umit Ugurlu
- Department of General Surgery, Marmara University School of Medicine, Istanbul, Turkey
| |
Collapse
|
7
|
Wu SS, Raymer C, Culbert A, Schafer R, Bernard S, Djohan R, Schwarz G, Bishop SN, Gurunian R. Predictors of Complications in Autologous Breast Reconstruction Using DIEP Flaps: Implications for Management. Plast Reconstr Surg 2023; 152:566e-577e. [PMID: 36862950 DOI: 10.1097/prs.0000000000010343] [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: 03/04/2023]
Abstract
BACKGROUND Deep inferior epigastric perforator (DIEP) flaps are the standard for autologous breast reconstruction. This study investigated risk factors for DIEP complications in a large, contemporary cohort to optimize surgical evaluation and planning. METHODS This retrospective study included patients who underwent DIEP breast reconstruction between 2016 and 2020 at an academic institution. Demographics, treatment, and outcomes were evaluated in univariable and multivariable regression models for postoperative complications. RESULTS In total, 802 DIEP flaps were performed in 524 patients (mean age, 51.2 ± 9.6 years; mean body mass index, 29.3 ± 4.5). Most patients (87%) had breast cancer; 15% were BRCA -positive. There were 282 (53%) delayed and 242 (46%) immediate reconstructions and 278 (53%) bilateral and 246 (47%) unilateral reconstructions. Overall complications occurred in 81 patients (15.5%), including venous congestion (3.4%), breast hematoma (3.6%), infection (3.6%), partial flap loss (3.2%), total flap loss (2.3%), and arterial thrombosis (1.3%). Longer operative time was significantly associated with bilateral immediate reconstructions and higher body mass index. Prolonged operative time (OR, 1.16; P = 0.001) and immediate reconstruction (OR, 1.92; P = 0.013) were significant predictors of overall complications. Partial flap loss was associated with bilateral immediate reconstructions, higher body mass index, current smoking status, and longer operative time. CONCLUSIONS Prolonged operative time is a significant risk factor for overall complications and partial flap loss in DIEP breast reconstruction. For each additional hour of surgical time, the risk of developing overall complications increases by 16%. These findings suggest that reducing operative time through co-surgeon approaches, consistency in surgical teams, and counseling patients with more risk factors toward delayed reconstructions may mitigate complications. CLINICAL QUESTION/LEVEL OF EVIDENCE Risk, III.
Collapse
Affiliation(s)
- Shannon S Wu
- From the Cleveland Clinic Lerner College of Medicine of Case Western Reserve University
| | - Charles Raymer
- Department of Plastic Surgery, Cleveland Clinic, Cleveland
| | - August Culbert
- From the Cleveland Clinic Lerner College of Medicine of Case Western Reserve University
| | - Rachel Schafer
- From the Cleveland Clinic Lerner College of Medicine of Case Western Reserve University
| | - Steven Bernard
- Department of Plastic Surgery, Cleveland Clinic, Cleveland
| | - Risal Djohan
- Department of Plastic Surgery, Cleveland Clinic, Cleveland
| | - Graham Schwarz
- Department of Plastic Surgery, Cleveland Clinic, Cleveland
| | - Sarah N Bishop
- Department of Plastic Surgery, Cleveland Clinic, Cleveland
| | - Raffi Gurunian
- Department of Plastic Surgery, Cleveland Clinic, Abu Dhabi
| |
Collapse
|
8
|
Wang Z, Jiao L, Chen S, Li Z, Xiao Y, Du F, Huang J, Long X. Flap perfusion assessment with indocyanine green angiography in deep inferior epigastric perforator flap breast reconstruction: A systematic review and meta-analysis. Microsurgery 2023; 43:627-638. [PMID: 37165852 DOI: 10.1002/micr.31056] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 04/01/2023] [Accepted: 04/27/2023] [Indexed: 05/12/2023]
Abstract
BACKGROUND Indocyanine green angiography (ICG-A) has been widely applied for intraoperative flap assessment in DIEP flap breast reconstruction. However, the beneficial effect of ICG-A in DIEP flap breast reconstruction is still uncertain and no standardized protocol is available. This study aims to analyze the clinical outcome and comprehensively review protocols of this field. METHODS A systematic review was conducted in MEDLINE, EMBASE, and Cochrane CENTRAL databases until September 15, 2022. Studies on the utility of intraoperative ICG-A in DIEP breast reconstruction were included. Data reporting reconstruction outcomes were extracted for pooled analysis. RESULTS A total of 22 studies were enrolled in the review, among five studies with 1021 patients included in the meta-analysis. The protocols of ICG-A assessment of DIEP flap varied among studies. According to the pooled results, the incidence of postoperative fat necrosis was 10.89% (50 of 459 patients) with ICG-A and 21.53% (121 of 562 patients) with clinical judgment. The risk for postoperative fat necrosis was significantly lower in patients with intraoperative ICG-A than without (RR 0.47 95% CI 0.29-0.78, p = .004, I2 = 51%). Reoperation occurred in 5 of 48 patients (10.42%) in the ICG-A group and in 21 of 64 patients (32.82%) in the control group summarized from reports in two studies. The risk for reoperation was lower in the ICG-A group than in the control group (RR 0.41 95% CI 0.18-0.93, p = .03, I2 = 0%). Other complications, including flap loss, seroma, hematoma, dehiscence, mastectomy skin necrosis, and infection, were comparable between the two groups. Heterogeneities among studies were acceptable. No significant influence of specific studies was identified in sensitivity analysis. CONCLUSIONS ICG-A is an accurate and reliable way to identify problematic perfusion of DIEP flaps during breast reconstruction. Protocols of ICG-A differed in current studies. Intraoperative ICG-A significantly decreases the rate of fat necrosis and reoperation in patients undergoing DIEP breast reconstruction. The synthesized results should be interpreted sensibly due to the sample size limitation. RCTs on the outcomes and high-quality studies for an optimized ICG-A protocol are still needed in the future.
Collapse
Affiliation(s)
- Zhaojian Wang
- Department of Plastic and Aesthetic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, People's Republic of China
| | - Ling Jiao
- Department of Dermatology, West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | - Siliang Chen
- Department of Dermatology, West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | - Zhijin Li
- Department of Plastic and Aesthetic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, People's Republic of China
| | - Yiding Xiao
- Department of Plastic and Aesthetic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, People's Republic of China
| | - Fengzhou Du
- Department of Plastic and Aesthetic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, People's Republic of China
| | - Jiuzuo Huang
- Department of Plastic and Aesthetic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, People's Republic of China
| | - Xiao Long
- Department of Plastic and Aesthetic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, People's Republic of China
| |
Collapse
|
9
|
Zaborowski AM, Heeney A, Walsh S, Barry M, Kell MR. Immediate breast reconstruction. Br J Surg 2023; 110:1039-1042. [PMID: 36972211 DOI: 10.1093/bjs/znad064] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 02/12/2023] [Indexed: 08/12/2023]
Affiliation(s)
| | - Anna Heeney
- Department of Breast Surgery, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Siun Walsh
- Department of Breast Surgery, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Mitchel Barry
- Department of Breast Surgery, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Malcolm R Kell
- Department of Breast Surgery, Mater Misericordiae University Hospital, Dublin, Ireland
| |
Collapse
|
10
|
Kim PJ, Yuan M, Wu J, Gallo L, Uhlman K, Voineskos SH, O’Neill A, Hofer SO. "Spin" in Observational Studies in Deep Inferior Epigastric Perforator Flap Breast Reconstruction: A Systematic Review. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e5095. [PMID: 37351115 PMCID: PMC10284325 DOI: 10.1097/gox.0000000000005095] [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: 01/24/2023] [Accepted: 04/26/2023] [Indexed: 06/24/2023]
Abstract
The deep inferior epigastric artery perforator (DIEP) flap is widely used in autologous breast reconstruction. However, the technique relies heavily on nonrandomized observational research, which has been found to have high risk of bias. "Spin" can be used to inappropriately present study findings to exaggerate benefits or minimize harms. The primary objective was to assess the prevalence of spin in nonrandomized observational studies on DIEP reconstruction. The secondary objectives were to determine the prevalence of each spin category and strategy. Methods MEDLINE and Embase databases were searched from January 1, 2015, to November 15, 2022. Spin was assessed in abstracts and full-texts of included studies according to criteria proposed by Lazarus et al. Results There were 77 studies included for review. The overall prevalence of spin was 87.0%. Studies used a median of two spin strategies (interquartile range: 1-3). The most common strategies identified were causal language or claims (n = 41/77, 53.2%), inadequate extrapolation to larger population, intervention, or outcome (n = 27/77, 35.1%), inadequate implication for clinical practice (n = 25/77, 32.5%), use of linguistic spin (n = 22/77, 28.6%), and no consideration of the limitations (n = 21/77, 27.3%). There were no significant associations between selected study characteristics and the presence of spin. Conclusions The prevalence of spin is high in nonrandomized observational studies on DIEP reconstruction. Causal language or claims are the most common strategy. Investigators, reviewers, and readers should familiarize themselves with spin strategies to avoid misinterpretation of research in DIEP reconstruction.
Collapse
Affiliation(s)
- Patrick J. Kim
- From the Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Morgan Yuan
- Division of Plastic, Reconstructive and Aesthetic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Jeremy Wu
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Lucas Gallo
- Division of Plastic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Kathryn Uhlman
- Division of Plastic, Reconstructive and Aesthetic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Sophocles H. Voineskos
- Division of Plastic, Reconstructive and Aesthetic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Anne O’Neill
- Division of Plastic, Reconstructive and Aesthetic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Stefan O.P. Hofer
- Division of Plastic, Reconstructive and Aesthetic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
11
|
Preoperative Perforator Mapping in DIEP Flaps for Breast Reconstruction. The Impact of New Contrast-Enhanced Ultrasound Techniques. J Pers Med 2022; 13:jpm13010064. [PMID: 36675725 PMCID: PMC9862612 DOI: 10.3390/jpm13010064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2022] [Revised: 12/15/2022] [Accepted: 12/19/2022] [Indexed: 12/29/2022] Open
Abstract
Deep inferior epigastric artery flaps (DIEP) represent the gold standard of autologous breast reconstruction. Due to significant variations in vascular anatomy, preoperative perforator mapping (PM) is mandatory in order to ensure the presence of a sufficient perforator within the flap. In this regard, CT angiography (CTA) is currently the method of choice. Therefore, we investigated the value of contrast-enhanced ultrasound (CEUS) techniques for preoperative PM in comparison to CTA. Patients underwent PM, utilizing both CTA and CEUS techniques. Documentation included the course of the vascular pedicle through the rectus muscle (M), fascial penetration (F), the subcutaneous plexus (P) and the skin point (SP) on either side of the abdomen. Thus, contrast-enhanced B-Flow (BCEUS), B-Flow ultrasound (BUS), CEUS, color Doppler ultrasound (CDUS) and CTA were evaluated in terms of the diagnostic consistency and effectiveness of PM. Precision (∆L) was then calculated in relation to the actual intraoperative location. Statistical analysis included Kruskall-Wallis, Levene and Bonferroni tests, as well as Spearman correlations. A total of 39 DIEP flaps were analyzed. Only CTA (∆L = 2.85 mm) and BCEUS (∆L = 4.57 mm) enabled complete PM, also including P and SP, whereas CDUS, CEUS and BUS enabled clear PM throughout M and F only. Regarding the number of detected perforators, PM techniques are ranked from high to low as follows: CTA, BCEUS, BUS, CEUS and CDUS. CTA and BCEUS showed sufficient diagnostic consistency for SP, P and F, while CDUS and CTA had a superior performance for M. BCEUS offers precise image-controlled surface tags and dynamic information for PM without imposing radiation and may, therefore, be considered a feasible add-on or alternative to CTA. However, BCEUS requires an experienced examiner and is more time-consuming.
Collapse
|
12
|
Abstract
Breast reconstruction is becoming increasingly recognized as a fundamental component in comprehensive breast cancer treatment. The primary goal for any reconstruction is to safely restore a natural appearing breast. When it comes to achieving the elements of size, shape, symmetry, and softness, the use of autologous tissue has many advantages. The approach to autologous breast reconstruction has changed substantially over the years as microsurgical free tissue transplants become more routine and accessible. While a variety of flap donor sites exist, careful flap selection based on surgical history and the availability of donor tissue is critical in achieving reliable results. This article reviews the clinical considerations in patient evaluation, donor site selection, and surgical approach taken at the Buncke Clinic.
Collapse
Affiliation(s)
- Rudolf Buntic
- Division of Microsurgery, The Buncke Clinic, San Francisco, California
| | - Alexander Y. Li
- Division of Plastic and Reconstructive Surgery, Stanford University, Stanford, California
| |
Collapse
|
13
|
Illg C, Krauss S, Rachunek K, Thiel JT, Daigeler A, Schäfer RC. Thermography Supported Color Duplex Ultrasound Accelerates ALT Perforator Imaging. J Reconstr Microsurg 2022; 39:295-300. [PMID: 36150693 DOI: 10.1055/s-0042-1755614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
BACKGROUND The anterolateral thigh flap is a versatile and dependable perforator flap and is a popular choice in the reconstruction of various body sites. The variable perforator anatomy suggests preoperative perforator imaging to improve safety and speed of dissection. An innovative perforator imaging technique is thermography, which lately gained attention in plastic surgery. METHODS Thirty-two healthy participants were included in this randomized study. One thigh was examined with dynamic infrared thermography and consecutively with ultrasound, while the contralateral thigh was examined with ultrasound as standalone technology. RESULTS The application of dynamic infrared thermography prior to ultrasound perforator identification significantly accelerated the ultrasound examination duration by 90 to 130 seconds. The mean duplex ultrasound examination duration correlated positively with the hotspot and perforator quantity per thigh. CONCLUSION The addition of thermographic perforator mapping can accelerate color duplex ultrasound anterolateral thigh perforator imaging. Furthermore, thermography supplements color duplex ultrasound with crucial information on angiosome location.
Collapse
Affiliation(s)
- Claudius Illg
- Department of Hand, Plastic, Reconstructive and Burn Surgery, BG Trauma Center Tuebingen, Eberhard Karls University Tuebingen, Tuebingen, Germany
| | - Sabrina Krauss
- Department of Hand, Plastic, Reconstructive and Burn Surgery, BG Trauma Center Tuebingen, Eberhard Karls University Tuebingen, Tuebingen, Germany
| | - Katarzyna Rachunek
- Department of Hand, Plastic, Reconstructive and Burn Surgery, BG Trauma Center Tuebingen, Eberhard Karls University Tuebingen, Tuebingen, Germany
| | - Johannes Tobias Thiel
- Department of Hand, Plastic, Reconstructive and Burn Surgery, BG Trauma Center Tuebingen, Eberhard Karls University Tuebingen, Tuebingen, Germany
| | - Adrien Daigeler
- Department of Hand, Plastic, Reconstructive and Burn Surgery, BG Trauma Center Tuebingen, Eberhard Karls University Tuebingen, Tuebingen, Germany
| | - Ruth Christine Schäfer
- Department of Hand, Plastic, Reconstructive and Burn Surgery, BG Trauma Center Tuebingen, Eberhard Karls University Tuebingen, Tuebingen, Germany
| |
Collapse
|
14
|
Simultaneous Contralateral Autologous Breast Augmentation during Unilateral Breast Reconstruction Utilizing Deep Inferior Epigastric Flaps. Plast Reconstr Surg Glob Open 2022; 10:e4498. [PMID: 36119381 PMCID: PMC9473798 DOI: 10.1097/gox.0000000000004498] [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: 05/17/2022] [Accepted: 06/30/2022] [Indexed: 11/26/2022]
Abstract
It is predicted that 281,550 new cases of invasive breast cancer and 49,290 new cases of ductal carcinoma in situ will be diagnosed this year. In this study, we will detail our experience with simultaneous contralateral autologous breast augmentation during unilateral breast reconstruction utilizing bilateral deep inferior epigastric perforator (DIEP) flaps. Methods A retrospective analysis of patients who underwent simultaneous contralateral autologous breast augmentation during unilateral breast reconstruction utilizing bilateral DIEP flaps by the senior surgeons at Beaumont Health Systems, Royal Oak, was conducted. Demographic data, operative details, complications, medical comorbidities, and patient outcomes were retrospectively analyzed. Results Seven patients who met the inclusion criteria were identified. One patient underwent immediate reconstruction with DIEP flaps, one patient had a history of lumpectomy and underwent delayed partial breast reconstruction, three patients had delayed unilateral DIEP breast reconstruction with contralateral breast augmentation, and two patients had previous augmentations that were revised. All patients examined in this review tolerated the procedures well and had clinically viable flaps along with superior aesthetic outcomes. Conclusions This technique can be applied to various clinical conditions, including immediate breast reconstruction, delayed breast reconstruction, and salvage for failed implant-based reconstruction, leading to optimal patient outcomes and satisfaction. Unilateral breast reconstruction with simultaneous contralateral autologous breast augmentation utilizing bilateral DIEP flaps is a surgical technique that more plastic surgeons should utilize.
Collapse
|
15
|
Atzeni M, Salzillo R, Haywood RM, Persichetti P, Ribuffo D, Figus A. Unilateral immediate deep inferior epigastric artery perforator flap breast reconstruction following skin sparing mastectomy: A comparative study on revision surgeries to improve breast symmetry. Microsurgery 2022; 42:766-774. [PMID: 35916342 DOI: 10.1002/micr.30945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Revised: 06/12/2022] [Accepted: 07/14/2022] [Indexed: 11/10/2022]
Abstract
BACKGROUND The number of revision surgeries to improve breast asymmetry after deep inferior epigastric perforator (DIEP) flap breast reconstruction is still high worldwide with impact on both patients and healthcare systems. These procedures include fat grafting, contralateral breast symmetrization, scar revision, flap repositioning and remodeling. A previously published DIEP flap insetting algorithm has proven to be effective in selecting patient-tailored strategies to achieve excellent aesthetic outcomes. This study investigated whether this insetting algorithm was effective in reducing revision surgeries in patients undergoing SSM and immediate DIEP flap breast reconstruction to achieve the goal of a one-stage reconstruction. METHODS This retrospective case-control study included 60 patients (group A) treated without the DIEP flap standardized insetting algorithm and 60 patients (group B) treated with the standardized insetting algorithm, which considers among its variables the type of breast to be reconstructed, abdominal tissue thickness, rotation due to harvesting side. Demographic data, operative data, complications and number of revision surgeries were recorded. RESULTS One hundred and twenty primary and 106 revision surgeries were performed. Groups were homogenous for age (p = .32), body mass index (p = .77), flap weight (p = .7), operative time (p = .87) and early complications (p = .78). When excluding isolated nipple reconstruction from the revision surgeries, one-stage reconstruction was successfully performed in 26 patients in group A (43.3%) and 39 patients (65.0%) in group B, with a statistically significant difference between the groups (p = .003). CONCLUSIONS The introduction of a standardized insetting algorithm for immediate unilateral DIEP flap breast reconstruction can be effective in reducing the number of revision surgeries for breast asymmetry, making a one-stage reconstruction an achievable and reliable target.
Collapse
Affiliation(s)
- Matteo Atzeni
- Faculty of Medicine and Surgery, Department of Surgical Sciences, Plastic Surgery and Microsurgery Unit, University of Cagliari, University Hospital Duilio Casula, Cagliari, Italy
| | - Rosa Salzillo
- Department of Plastic, Reconstructive and Aesthetic Surgery, Campus Bio-Medico University of Rome, University Hospital Campus Bio-Medico, Rome, Italy
| | - Richard M Haywood
- Norwich Medical School, University of East Anglia, Norfolk and Norwich University Hospital NHS Foundation Trust, Norwich, UK
| | - Paolo Persichetti
- Department of Plastic, Reconstructive and Aesthetic Surgery, Campus Bio-Medico University of Rome, University Hospital Campus Bio-Medico, Rome, Italy
| | - Diego Ribuffo
- Department of Surgery, Plastic Surgery Unit, Sapienza University of Rome, Rome, Italy
| | - Andrea Figus
- Faculty of Medicine and Surgery, Department of Surgical Sciences, Plastic Surgery and Microsurgery Unit, University of Cagliari, University Hospital Duilio Casula, Cagliari, Italy
| |
Collapse
|
16
|
Comparing Donor Site Morbidity for Autologous Breast Reconstruction: Thigh vs. Abdomen. Plast Reconstr Surg Glob Open 2022; 10:e4215. [PMID: 35350144 PMCID: PMC8947678 DOI: 10.1097/gox.0000000000004215] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Revised: 03/24/2022] [Accepted: 01/25/2022] [Indexed: 11/25/2022]
Abstract
Although abdominally-based free flaps have long been the gold standard, the profunda artery perforator (PAP) flap has emerged as an important alternative option for autologous breast reconstruction. The aim of this study was to directly compare the donor site morbidity of using the PAP versus deep inferior epigastric perforator (DIEP) free flap.
Collapse
|
17
|
Moellhoff N, Prantl L, Fritschen U, Germann G, Giunta RE, Kehrer A, Aung T, Zeman F, Broer PN, Heidekrueger PI. Uni-vs. bilateral DIEP flap reconstruction - A multicenter outcome analysis. Surg Oncol 2021; 38:101605. [PMID: 34022504 DOI: 10.1016/j.suronc.2021.101605] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 04/23/2021] [Accepted: 05/11/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Over the past decade numbers of bilateral mastectomy have increased steadily. As a result, bilateral breast reconstruction is gaining popularity. The presented study compares complications and outcomes of unilateral and bilateral DIEP free-flap breast reconstructions using the largest database available in Europe. METHODS Female breast cancer patients (n = 3926) receiving DIEP flap breast reconstructions (n = 4577 free flaps) at 22 different centers were included in this study. Free flaps were stratified into two groups: a unilateral- (UL) and a bilateral- (BL) breast reconstruction group. Groups were compared with regard to surgical complications and free flap outcome. RESULTS Mean operative time was significantly longer in the BL group (UL: 285.2 ± 107.7 vs. BL: 399.1 ± 136.8 min; p < 0.001). Mean ischemia time was comparable between groups (p = 0.741). There was no significant difference with regard to total (UL 1.8% vs. BL 2.6%, p = 0.081) or partial flap loss (UL 1.2% vs. BL 0.9%, p = 0.45) between both groups. Rates of venous or arterial thrombosis were comparable between both groups (venous: UL 2.9% vs. BL 2.2%, p = 0.189; arterial: UL 1.8% vs. BL 1.2%, p = 0.182). However, significantly higher rates of hematoma at the donor and recipient site were observed in the UL group (donor site: UL 1.1% vs. BL 0.1%, p = 0.001; recipient site UL 3.9% vs. BL 1.7%, p < 0.001). CONCLUSIONS The data underline the feasibility of bilateral DIEP flap reconstruction, when performed in a setting of specialized centers.
Collapse
Affiliation(s)
- N Moellhoff
- Division of Hand, Plastic and Aesthetic Surgery, University Hospital, LMU Munich, Germany
| | - L Prantl
- Centre of Plastic, Aesthetic, Hand and Reconstructive Surgery, University of Regensburg, Germany.
| | - Uv Fritschen
- Department of Plastic and Esthetic Surgery, Hand Surgery, Helios Hospital Emil von Behring, Berlin, Germany
| | - G Germann
- Department of Plastic, Reconstructive, Esthetic and Handsurgery, ETHIANUM Klinik Heidelberg, Germany
| | - R E Giunta
- Division of Hand, Plastic and Aesthetic Surgery, University Hospital, LMU Munich, Germany
| | - A Kehrer
- Centre of Plastic, Aesthetic, Hand and Reconstructive Surgery, University of Regensburg, Germany
| | - T Aung
- Centre of Plastic, Aesthetic, Hand and Reconstructive Surgery, University of Regensburg, Germany
| | - F Zeman
- Center for Clinical Studies, University Medical Center Regensburg, Regensburg, Germany
| | - P N Broer
- Department of Plastic, Reconstructive, Hand and Burn Surgery, Bogenhausen Academic Teaching Hospital, Munich, Germany
| | - P I Heidekrueger
- Centre of Plastic, Aesthetic, Hand and Reconstructive Surgery, University of Regensburg, Germany
| |
Collapse
|
18
|
Kelling JA, Meade A, Adkins M, Zhang AY. Risk of Pneumothorax With Internal Mammary Vessel Utilization in Autologous Breast Reconstruction. Ann Plast Surg 2021; 86:S184-S188. [PMID: 33470623 DOI: 10.1097/sap.0000000000002643] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Complications associated with autologous breast reconstruction are well reported in the literature. Regardless of the type of free flap harvested, the anastomosis is most commonly performed to the recipient internal mammary vessels. Although pneumothorax is a known possible complication of breast surgery, incidence of pneumothorax in breast reconstruction involving the use of the internal mammary vessels is rarely discussed. The aim of our study was to determine the incidence of pneumothorax in deep inferior epigastric perforator (DIEP) flap breast reconstruction. METHODS A single-institution review was performed examining the incidence of pneumothorax in cases of DIEP flap breast reconstruction with anastomosis to the internal mammary vessels over a 4-year period. Intraoperative irrigation was used to visually assess for evidence of pneumothorax during recipient vessel dissection and anastomosis. Anteroposterior chest radiographs were obtained on the first postoperative day to assess for pneumothorax. Additional variables analyzed included type of retractor used during recipient vessel dissection and history of radiation. RESULTS A total of 180 patients underwent autologous DIEP breast reconstruction at our institution. The overall incidence of pneumothorax was 1.4 per 100 recipient vessel dissections and 2.2 per 100 patients undergoing breast reconstruction. There was a total of 4 cases of pneumothorax. Three were attributed to unknown causes, and 1 was due to direct injury to the parietal pleura via electrocautery. CONCLUSION The use of the internal mammary artery and vein as recipient vessels continues to be the most common and reliable recipient for autologous breast reconstruction. Based on our data, pneumothorax does not seem to be a common complication of this procedure. If concern for iatrogenic injury to the pleura arises intraoperatively, we suggest the use of a saline bubble test to investigate the possible injury. Routine postoperative radiographs are not indicated unless the patient develops symptoms suggestive of pneumothorax.
Collapse
Affiliation(s)
- Joseph A Kelling
- From the Department of Plastic Surgery, University of Texas at Southwestern Medical Center, Dallas, TX
| | | | | | | |
Collapse
|
19
|
Kiely J, Kumar M, Wade RG. The accuracy of different modalities of perforator mapping for unilateral DIEP flap breast reconstruction: A systematic review and meta-analysis. J Plast Reconstr Aesthet Surg 2020; 74:945-956. [PMID: 33342741 DOI: 10.1016/j.bjps.2020.12.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Revised: 10/21/2020] [Accepted: 12/02/2020] [Indexed: 01/23/2023]
Abstract
BACKGROUND Perforator mapping may be performed prior to deep inferior epigastric perforator (DIEP) flap breast reconstruction to guide perforator selection. However, the accuracy of different imaging modalities remains unknown. This review aimed to evaluate the accuracy of different modalities for locating perforators for unipedicled DIEP flap breast reconstruction. METHODS MEDLINE and EMBASE were searched from inception to 24th September 2019 for studies concerning adult women undergoing DIEP flap breast reconstruction with preoperative perforator mapping. The index test was pre-operative imaging and the reference standard was intraoperative identification. RESULTS 21 articles with 1146 women were included. Six methods were described; handheld doppler, colour doppler (duplex) ultrasonography, computed tomography angiography, magnetic resonance angiography (MRA), direct infrared thermography with and without doppler. Meta-analysis revealed 94% (95% CI 88-99%) of DIEPs identified as the 'dominant perforator' on imaging were chosen as dominant perforators intraoperatively. Colour doppler (Duplex) ultrasonography had the lowest agreement (mean 74% [95% CI 67-81%]) whilst MRA had the highest agreement (mean 97% [95% CI 86-100%]). There was no statistically significant difference in the performance of different tests. All studies were subject to bias as the operators had knowledge of the index test prior to conducting the reference standard. CONCLUSIONS Based upon limited evidence, cross sectional (CT/MR) imaging modalities for preoperative DIEP mapping appear to have similar accuracy and perform better than ultrasound.
Collapse
Affiliation(s)
- John Kiely
- Department of Plastic and Reconstructive Surgery, Bradford Teaching Hospitals Trust, Bradford, UK.
| | - Mayank Kumar
- Department of Trauma & Orthopaedics, Leeds Teaching Hospitals Trust, Leeds, UK
| | - Ryckie G Wade
- Department of Plastic and Reconstructive Surgery, Leeds Teaching Hospitals Trust, Leeds, UK; Leeds Institute for Medical Research, The University of Leeds, Leeds, UK
| |
Collapse
|
20
|
Tallroth L, Velander P, Klasson S. A short-term comparison of expander prosthesis and DIEP flap in breast reconstructions: A prospective randomized study. J Plast Reconstr Aesthet Surg 2020; 74:1193-1202. [PMID: 33436336 DOI: 10.1016/j.bjps.2020.10.104] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Revised: 08/25/2020] [Accepted: 10/27/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND There is yet no clear consensus on which method is preferable in secondary breast reconstructions, prosthesis, or autologous tissue. METHODS In this first prospective randomized study, 29 women underwent reconstruction with expander prosthesis (EP) and 44 with deep inferior epigastric perforator (DIEP) flap. Inclusion started in 2012 and ended in 2018. Demographic data, complications, surgery time, hospital days, and consulting visits were recorded. Patient satisfaction was evaluated pre- and postoperatively using the BREAST-Q questionnaire. Health care costs were calculated based on rates from the financial year 2018. Here, we report the results related to the surgery and the first 30 postoperative days. RESULTS The two groups were comparable regarding demographics and clinical characteristics. Satisfaction with breasts, measured with BREAST-Q, was significantly higher in patients who had undergone reconstruction with DIEP flap compared with EP. Within 30 days after breast reconstruction, significantly fewer women (n = 2) in the EP group suffered complications compared to the DIEP flap group (n = 16; p < 0.01). The health care cost was also significantly higher in the DIEP flap group relative to the EP group (p < 0.01). DISCUSSION This patient cohort will be studied systematically over time, and results concerning the need for complementary surgery, costs, esthetics, and the patient-reported outcome (PRO) will be reported in future work. In this short-term report, EP seems to be preferable in regard to cost and complications, and DIEP flap is to choose from the patient's perspective.
Collapse
Affiliation(s)
- Linda Tallroth
- Skåne University Hospital, Department of Plastic and Reconstructive Surgery, Jan Waldenströms gata 18, 20501 Malmö, Sweden
| | - Patrik Velander
- Skåne University Hospital, Department of Plastic and Reconstructive Surgery, Jan Waldenströms gata 18, 20501 Malmö, Sweden
| | - Stina Klasson
- Skåne University Hospital, Department of Plastic and Reconstructive Surgery, Jan Waldenströms gata 18, 20501 Malmö, Sweden.
| |
Collapse
|
21
|
Mulier H, De Frene B, Benmeridja L, Vanhoorebeeck F, Denis B, Casaer B, Rogge FJ, Leleu K, Mulier J. Impact of opioid-free anesthesia on complications after deep inferior epigastric perforator flap surgery: A retrospective cohort study. J Plast Reconstr Aesthet Surg 2020; 74:504-511. [PMID: 33268289 DOI: 10.1016/j.bjps.2020.09.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2020] [Revised: 05/06/2020] [Accepted: 09/27/2020] [Indexed: 11/16/2022]
Abstract
This study measured the number of complications after deep inferior epigastric perforator (DIEP) flap reconstruction performed under opioid-free anesthesia (OFA) combined with goal-directed fluid therapy or opioid anesthesia with liberal fluid therapy (OA). This retrospective cohort study consisted of 204 patients who underwent DIEP flap reconstruction at AZSint Jan Brugge between April 2014 and March 2019. Primary outcomes were complications, according to the Clavien-Dindo classification and the length of hospital stay (LOS). The secondary outcomes were flap failure, postoperative nausea and vomiting (PONV), postoperative pain, postoperative opioid consumption, and postoperative skin flap temperature. OFA included a combination of dexmedetomidine, lidocaine, and ketamine without any opioid administered pre- or intraoperatively. OA included a combination of sufentanil and remifentanil. OFA patients received strict goal-directed fluid therapy, whereas OA patients received liberal fluids to maintain perfusion pressure. All patients except 7 (TIVA with remifentanil) received inhalation anesthesia combined with an infusion of propofol. Of the 204 patients, 55 received OFA and 149 received OA. There were no differences in major complications, but fewer minor complications in the OFA group (17.9% vs. 51.4% and P < 0.001). Flap failure occurred in three patients of the OA group. Six patients developed flap thrombosis (five OA patients and one OFA patient). OFA was associated with fewer postoperative opioids, shorter LOS, less PONV, and less pain. In patients without previous nausea, the PONV incidence was higher in the OA group than in the OFA group (12.7% vs. 43.6% and P < 0.001). Patients with previous nausea more frequently required postoperative opioids and had a nausea rate of 60.87%.
Collapse
Affiliation(s)
- Harold Mulier
- KU Leuven - University of Leuven, Herestraat 49, B-3000 Leuven, Belgium
| | - Bob De Frene
- Department of Plastic and Reconstructive Surgery, AZSint Jan AV Brugge-Oostende, Campus Brugge, Ruddershove 10, B-8000 Brugge, Belgium
| | - Lara Benmeridja
- Department of Plastic and Reconstructive Surgery, AZSint Jan AV Brugge-Oostende, Campus Brugge, Ruddershove 10, B-8000 Brugge, Belgium; Department of Plastic and Reconstructive Surgery, Ghent University Hospital, B-9000 Ghent, Belgium
| | - Florian Vanhoorebeeck
- Department of Anesthesiology, Intensive Care and Reanimation, AZSint Jan Brugge-Oostende, Campus Brugge, Ruddershove 10, B-8000 Brugge, Belgium
| | - Bruno Denis
- Department of Anesthesiology, Intensive Care and Reanimation, AZSint Jan Brugge-Oostende, Campus Brugge, Ruddershove 10, B-8000 Brugge, Belgium; Department of Anesthesiology and Acute Pain Service, Cliniques Universitaires Saint Luc, University Catholic of Louvain, av Hippocrate 10, B-1200 Brussels, Belgium
| | - Bob Casaer
- Department of Plastic and Reconstructive Surgery, AZSint Jan AV Brugge-Oostende, Campus Brugge, Ruddershove 10, B-8000 Brugge, Belgium
| | - Fabrice Jacques Rogge
- Department of Plastic and Reconstructive Surgery, AZSint Jan AV Brugge-Oostende, Campus Brugge, Ruddershove 10, B-8000 Brugge, Belgium
| | - Kris Leleu
- Department of Anesthesiology, Intensive Care and Reanimation, AZSint Jan Brugge-Oostende, Campus Brugge, Ruddershove 10, B-8000 Brugge, Belgium
| | - Jan Mulier
- KU Leuven - University of Leuven, Herestraat 49, B-3000 Leuven, Belgium; Department of Anesthesiology, Intensive Care and Reanimation, AZSint Jan Brugge-Oostende, Campus Brugge, Ruddershove 10, B-8000 Brugge, Belgium; UGhent - University of Ghent, B-9000 Ghent, Belgium.
| |
Collapse
|
22
|
Bilateral Simultaneous Breast Reconstruction with DIEP- and TMG Flaps: Head to Head Comparison, Risk and Complication Analysis. J Clin Med 2020; 9:jcm9072031. [PMID: 32605294 PMCID: PMC7409039 DOI: 10.3390/jcm9072031] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Revised: 06/11/2020] [Accepted: 06/16/2020] [Indexed: 11/16/2022] Open
Abstract
Background: A two center retrospective cohort study of simultaneous bilateral breast reconstructions using double deep inferior epigastric perforator (DIEP) flaps and double transverse myocutaneous/upper gracilis (TMG) flaps was conducted. The aim of this study was to compare surgical procedures, complications, and overall outcome. Patients and Methods: Two study groups, either receiving a simultaneous bilateral breast reconstruction, with double DIEP flaps (n = 152) in group 1, or double TMG flaps (n = 86) in group 2, were compared. A detailed risk and complication analysis was performed. Patient characteristics, operative time and the need for further operations were evaluated. Results: Double DIEP patients had donor site complications in 23.7% and double TMG patients in 16.3% (p = 0.9075, RR 1.45). Flap loss rates of 3.5% (double TMG) and 2.6% (double DIEP) were recorded (p = 0.7071, RR 1.33). The need for postoperative lipofilling was significantly higher in double TMG patients (65.1% vs. 38.2 %, p = 0.0047, RR 1.71). Conclusion: Complication analysis favors the double DIEP procedure. Donor site morbidity was lower and less severe in the double TMG group. Later fat grafting was more frequently needed after double TMG reconstructions. Further studies, preferably of prospective nature, are needed to evaluate the benefit of bilateral simultaneous breast reconstructions.
Collapse
|
23
|
Risk-reducing mastectomy: a case series of 124 procedures in Brazilian patients. Breast Cancer Res Treat 2020; 181:69-75. [PMID: 32215763 DOI: 10.1007/s10549-020-05582-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Accepted: 02/20/2020] [Indexed: 02/08/2023]
Abstract
PURPOSE Women with mutations in breast cancer predisposition genes have a significantly higher lifetime risk of developing breast cancer and can opt for risk-reducing mastectomy. Women with positive family history of cancer can also opt for prophylactic surgery as a preventive method in selected cases. Current studies showed reduced risk of developing breast cancer after prophylactic nipple-sparing mastectomy, however, despite the good clinical outcomes, one of the main concerns regarding nipple-sparing mastectomy (NSM) is the oncological safety of nipple-areola complex preservation. In this study, we aimed to evaluate the indications, complication rates, and unfavorable events of 62 Brazilian patients that underwent risk-reducing NSM from 2004 to 2018. METHODS Patient data were reviewed retrospectively and descriptive statistics were utilized to summarize the findings. RESULTS The mean patients age was 43.8 years. The main indication for risk-reducing NSM was the presence of pathogenic mutation (53.3%), followed by atypia or lobular carcinoma in situ (25.8), and family history of breast cancer and/or ovarian cancer (20.9%). There were four (3.2%) incidental diagnosis of ductal carcinoma in situ and one invasive ductal carcinoma (0.8%). From the 124 prophylactic NSM performed, two (1.6%) complications had occurred: one (0.8%) infection and one (0.8%) partial nipple necrosis. In a mean follow-up of 50 months, there was one (1.6%) newly diagnosed breast cancer in the 62 patients undergoing prophylactic NSM. CONCLUSIONS Our findings demonstrated efficacy and safety to perform NSM as prophylactic surgery with good oncological outcomes and low complication rates in a case series of Brazilian patients.
Collapse
|
24
|
O'Neill AC, Yang D, Roy M, Sebastiampillai S, Hofer SOP, Xu W. Development and Evaluation of a Machine Learning Prediction Model for Flap Failure in Microvascular Breast Reconstruction. Ann Surg Oncol 2020; 27:3466-3475. [PMID: 32152777 DOI: 10.1245/s10434-020-08307-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Indexed: 12/18/2022]
Abstract
BACKGROUND Despite high success rates, flap failure remains an inherent risk in microvascular breast reconstruction. Identifying patients who are at high risk for flap failure would enable us to recommend alternative reconstructive techniques. However, as flap failure is a rare event, identification of risk factors is statistically challenging. Machine learning is a form of artificial intelligence that automates analytical model building. It has been proposed that machine learning can build superior prediction models when the outcome of interest is rare. METHODS In this study we evaluate machine learning resampling and decision-tree classification models for the prediction of flap failure in a large retrospective cohort of microvascular breast reconstructions. RESULTS A total of 1012 patients were included in the study. Twelve patients (1.1%) experienced flap failure. The ROSE informed oversampling technique and decision-tree classification resulted in a strong prediction model (AUC 0.95) with high sensitivity and specificity. In the testing cohort, the model maintained acceptable specificity and predictive power (AUC 0.67), but sensitivity was reduced. The model identified four high-risk patient groups. Obesity, comorbidities and smoking were found to contribute to flap loss. The flap failure rate in high-risk patients was 7.8% compared with 0.44% in the low-risk cohort (p = 0.001). CONCLUSIONS This machine-learning risk prediction model suggests that flap failure may not be a random event. The algorithm indicates that flap failure is multifactorial and identifies a number of potential contributing factors that warrant further investigation.
Collapse
Affiliation(s)
- Anne C O'Neill
- Division of Plastic Surgery, Department of Surgery and Surgical Oncology, University Health Network, University of Toronto, Toronto, Canada. Anne.O'
| | - Donyang Yang
- Department of Biostatistics, Princess Margaret Cancer Centre, University Health Network, Toronto, Canada
| | - Melissa Roy
- Division of Plastic Surgery, Department of Surgery and Surgical Oncology, University Health Network, University of Toronto, Toronto, Canada
| | - Stephanie Sebastiampillai
- Division of Plastic Surgery, Department of Surgery and Surgical Oncology, University Health Network, University of Toronto, Toronto, Canada
| | - Stefan O P Hofer
- Division of Plastic Surgery, Department of Surgery and Surgical Oncology, University Health Network, University of Toronto, Toronto, Canada
| | - Wei Xu
- Department of Biostatistics, Princess Margaret Cancer Centre, University Health Network, Toronto, Canada
| |
Collapse
|
25
|
Bennett KG, Qi J, Kim HM, Hamill JB, Pusic AL, Wilkins EG. Comparison of 2-Year Complication Rates Among Common Techniques for Postmastectomy Breast Reconstruction. JAMA Surg 2019; 153:901-908. [PMID: 29926077 DOI: 10.1001/jamasurg.2018.1687] [Citation(s) in RCA: 157] [Impact Index Per Article: 31.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance In breast reconstruction, it is critical for patients and surgeons to have comprehensive information on the relative risks of the available options. However, previous studies that evaluated complications were limited by single-center designs, inadequate follow-up, and confounding. Objective To assess 2-year complication rates across common techniques for postmastectomy reconstruction in a multicenter patient population. Design, Setting, and Participants This longitudinal, multicenter, prospective cohort study conducted from February 1, 2012, through July 31, 2015, took place at the 11 study sites associated with the Mastectomy Reconstruction Outcomes Consortium study. Eligible patients included women 18 years and older presenting for first-time breast reconstruction with at least 2 years of follow-up. Procedures evaluated included direct-to-implant (DTI) technique, expander-implant (EI) technique, latissimus dorsi (LD) flap, pedicled transverse rectus abdominis myocutaneous (pTRAM) flap, free transverse rectus abdominis myocutaneous (fTRAM) flap, deep inferior epigastric perforator (DIEP) flap, and superficial inferior epigastric artery (SIEA) flap. Interventions Postmastectomy breast reconstruction. Main Outcomes and Measures Development of complications, reoperative complications, and wound infections during 2-year follow-up. Mixed-effects logistic regression analysis controlled for variability among centers and for demographic and clinical variables. Results A total of 2343 patients (mean [SD] age, 49.5 [10.1] years; mean [SD] body mass index, 26.6 [5.7]) met the inclusion criteria. A total of 1525 patients (65.1%) underwent EI reconstruction, with 112 (4.8%) receiving DTI reconstruction, 85 (3.6%) pTRAM flaps, 95 (4.1%) fTRAM flaps, 390 (16.6%) DIEP flaps, 71 (3.0%) LD flaps, and 65 (2.8%) SIEA flaps. Overall, complications were noted in 771 (32.9%), with reoperative complications in 453 (19.3%) and wound infections in 230 (9.8%). Two years postoperatively, patients undergoing any autologous reconstruction type had significantly higher odds of developing any complication compared with those undergoing EI reconstruction (pTRAM flap: odds ratio [OR], 1.91; 95% CI, 1.10-3.31; P = .02; fTRAM flap: OR, 2.05; 95% CI, 1.24-3.40; P = .005; DIEP flap: OR, 1.97; 95% CI, 1.41-2.76; P < .001; LD flaps: OR, 1.87; 95% CI, 1.03-3.40; P = .04; SIEA flap: OR, 4.71; 95% CI, 2.32-9.54; P < .001). With the exception of LD flap reconstructions, all flap procedures were associated with higher odds of reoperative complications (pTRAM flap: OR, 2.48; 95% CI, 1.33-4.64; P = .005; fTRAM flap: OR, 3.02; 95% CI, 1.73-5.29; P < .001; DIEP flap: OR, 2.76; 95% CI, 1.87-4.07; P < .001; SIEA flap: OR, 2.62; 95% CI, 1.24-5.53; P = .01) compared with EI techniques. Of the autologous reconstructions, only patients undergoing DIEP flaps had significantly lower odds of infection compared with those undergoing EI procedures (OR, 0.45; 95% CI, 0.25-0.29; P = .006). However, DTI and EI procedures had higher failure rates (EI and DTI techniques, 7.1%; pTRAM flap, 1.2%; fTRAM flap, 2.1%; DIEP flap, 1.3%; LD flap, 2.8%; and SIEA flap, 0%; P < .001). Conclusions and Relevance Significant differences were noted across reconstructive procedure types for overall and reoperative complications, which is critically important information for women and surgeons making breast reconstruction decisions.
Collapse
Affiliation(s)
- Katelyn G Bennett
- Section of Plastic Surgery, Department of Surgery, University of Michigan, Ann Arbor
| | - Ji Qi
- Section of Plastic Surgery, Department of Surgery, University of Michigan, Ann Arbor
| | - Hyungjin M Kim
- Center for Statistical Consultation and Research, University of Michigan, Ann Arbor.,Department of Biostatistics, University of Michigan, Ann Arbor
| | - Jennifer B Hamill
- Section of Plastic Surgery, Department of Surgery, University of Michigan, Ann Arbor
| | - Andrea L Pusic
- Plastic and Reconstructive Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Edwin G Wilkins
- Section of Plastic Surgery, Department of Surgery, University of Michigan, Ann Arbor
| |
Collapse
|
26
|
Bilateral DIEP Flap Breast Reconstruction to a Single Set of Internal Mammary Vessels: Technique, Safety, and Outcomes after 250 Flaps. Plast Reconstr Surg 2019; 144:554e-564e. [PMID: 31568283 DOI: 10.1097/prs.0000000000006066] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The deep inferior epigastric artery perforator (DIEP) flap is considered the gold standard in autologous breast reconstruction. In bilateral cases, both flaps are often anastomosed to the internal mammary vessels on either side of the sternum. The authors propose a method in which both flaps are anastomosed to only the right side internal mammary artery and vein. METHODS Between November of 2009 and March of 2018, 125 patients underwent bilateral DIEP flap breast reconstruction with this technique. One flap is perfused by the anterograde proximal internal mammary artery and the second one by the retrograde distal internal mammary artery after presternal tunneling. Patient demographics and operative details were reviewed retrospectively. RESULTS Two hundred fifty flaps were performed. One hundred fifty-two flaps were prophylactic or primary reconstructions (60.8 percent), 70 were secondary reconstructions (28 percent), and 28 were tertiary reconstructions (11.2 percent). Mean patient age was 46 years, and the mean body mass index was 25 kg/m. Sixty patients underwent radiation therapy or chemotherapy (48 percent). The authors encountered one significant partial failure (0.4 percent) and nine complete flap failures (3.6 percent). The authors did not see a statistically significant predisposition for failure comparing the retrograde with the anterograde flow flaps, nor when comparing the tunneled with the nontunneled flaps. CONCLUSIONS The authors' results show that anastomosing both DIEP flaps to a single set of mammary vessels is safe and reliable. The authors conclude that the retrograde flow through the distal internal mammary artery is sufficient for free flap perfusion and that subcutaneous tunneling of a free flap pedicle does not predispose to flap failure. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.
Collapse
|
27
|
Zhang Q, Xiao Q, Guo R, Xiu B, Li L, Chi W, Gu Y, Wu J. Applications of rib sparing technique in internal mammary vessels exposure of abdominal free flap breast reconstructions: a 12-year single-center experience of 215 cases. Gland Surg 2019; 8:477-485. [PMID: 31741878 DOI: 10.21037/gs.2019.08.08] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Internal mammary vessels (IMVs) are widely used recipient vessels in abdominal free flap breast reconstructions. Rib sparing technique is an alternative method with less damage in IMVs exposure. This study aims to investigate the factors influencing the selection of IMVs, as well as analyze the applicability and related factors of rib sparing technique in abdominal breast reconstruction. Methods Medical records of 215 patients who underwent abdominal free flap reconstruction from November 2006 to December 2017 in Fudan University Shanghai Cancer Center (FUSCC) were analyzed. Intercostal space (ICS) was measured from preoperative chest computed tomography scan. Factors influencing the choice of recipient vessels and rib sparing were analyzed. Surgery time, hospitalization and complications were assessed. Results Among all 218 flaps, 172 flaps used IMVs as the recipient vessels while 46 used other vessels. patients with immediate reconstruction (P=0.005) and axillary lymph nodes dissection (ALND) (P<0.001) were less likely to use IMVs. Patients' body mass index (BMI) and radiotherapy history showed no statistically significant differences between the two groups (P=0.338 and 0.811). In IMVs group, 62% cases used rib sparing technique. Compared with rib resection group, patients with rib sparing were taller (P=0.047) and with a wider ICS (2.65±0.54 vs. 2.25±0.38 cm, P<0.001). Rib sparing group had a shorter surgery and postoperative hospitalization time, as well as a lower complication rate, but the differences were not statistically significant (P=0.120, 0.450 and 0.612). Conclusions IMVs were used more frequently as the recipient vessels in abdominal free flap breast reconstructions, especially when axillary operation was not performed at the same time. Rib sparing technique had the potential to decrease surgery time, hospitalization days and complications rate. It could be applied in most of the patients with IMVs exposure, particularly in taller patients and patients with a wider ICS. Preoperative chest computed tomography scan can be used to assess the ICS width to provide operational suggestions.
Collapse
Affiliation(s)
- Qi Zhang
- Department of Breast Surgery, Breast Cancer Institute, Fudan University Shanghai Cancer Center, Shanghai 200032, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Qin Xiao
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China.,Department of Radiology, Fudan University Shanghai Cancer Center, Shanghai 200032, China
| | - Rong Guo
- Department of Breast Surgery, Breast Cancer Institute, Fudan University Shanghai Cancer Center, Shanghai 200032, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Bingqiu Xiu
- Department of Breast Surgery, Breast Cancer Institute, Fudan University Shanghai Cancer Center, Shanghai 200032, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Lun Li
- Department of Breast Surgery, Breast Cancer Institute, Fudan University Shanghai Cancer Center, Shanghai 200032, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Weiru Chi
- Department of Breast Surgery, Breast Cancer Institute, Fudan University Shanghai Cancer Center, Shanghai 200032, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Yajia Gu
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China.,Department of Radiology, Fudan University Shanghai Cancer Center, Shanghai 200032, China
| | - Jiong Wu
- Department of Breast Surgery, Breast Cancer Institute, Fudan University Shanghai Cancer Center, Shanghai 200032, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China.,Collaborative Innovation Center for Cancer Medicine, Shanghai 200032, China
| |
Collapse
|
28
|
Roy M, Sebastiampillai S, Haykal S, Zhong T, Hofer SOP, O'Neill AC. Development and validation of a risk stratification model for immediate microvascular breast reconstruction. J Surg Oncol 2019; 120:1177-1183. [DOI: 10.1002/jso.25714] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Accepted: 09/08/2019] [Indexed: 01/10/2023]
Affiliation(s)
- Mélissa Roy
- Division of Plastic and Reconstructive Surgery, Department of SurgeryUniversity of Toronto Toronto Ontario Canada
- Division of Plastic and Reconstructive Surgery, Department of Surgical OncologyUniversity Health Network, University of Toronto Toronto Ontario Canada
| | - Stephanie Sebastiampillai
- Division of Plastic and Reconstructive Surgery, Department of Surgical OncologyUniversity Health Network, University of Toronto Toronto Ontario Canada
| | - Siba Haykal
- Division of Plastic and Reconstructive Surgery, Department of SurgeryUniversity of Toronto Toronto Ontario Canada
- Division of Plastic and Reconstructive Surgery, Department of Surgical OncologyUniversity Health Network, University of Toronto Toronto Ontario Canada
| | - Toni Zhong
- Division of Plastic and Reconstructive Surgery, Department of SurgeryUniversity of Toronto Toronto Ontario Canada
- Division of Plastic and Reconstructive Surgery, Department of Surgical OncologyUniversity Health Network, University of Toronto Toronto Ontario Canada
| | - Stefan O. P. Hofer
- Division of Plastic and Reconstructive Surgery, Department of SurgeryUniversity of Toronto Toronto Ontario Canada
- Division of Plastic and Reconstructive Surgery, Department of Surgical OncologyUniversity Health Network, University of Toronto Toronto Ontario Canada
| | - Anne C. O'Neill
- Division of Plastic and Reconstructive Surgery, Department of SurgeryUniversity of Toronto Toronto Ontario Canada
- Division of Plastic and Reconstructive Surgery, Department of Surgical OncologyUniversity Health Network, University of Toronto Toronto Ontario Canada
| |
Collapse
|
29
|
Anker AM, Prantl L, Strauss C, Brébant V, Schenkhoff F, Pawlik M, Vykoukal J, Klein SM. Assessment of DIEP Flap Perfusion with Intraoperative Indocyanine Green Fluorescence Imaging in Vasopressor-Dominated Hemodynamic Support Versus Liberal Fluid Administration: A Randomized Controlled Trial With Breast Cancer Patients. Ann Surg Oncol 2019; 27:399-406. [PMID: 31468214 DOI: 10.1245/s10434-019-07758-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2019] [Indexed: 01/14/2023]
Abstract
BACKGROUND Dogmatic denial of vasopressor agents for blood pressure regulation during free-flap surgery is associated with concomitant large-volume intraoperative fluid administration. Yet, the doctrinal banning of vasopressors during microvascular breast reconstruction still is a subject of controversy. Several retrospective observations have recently drawn attention to serious iatrogenic consequences of intravenous crystalloid overload in microsurgery such as thrombus formation and increased flap failure rates. METHODS This prospective randomized controlled trial investigated the potential effects of fluid-restrictive vasopressor-dominated hemodynamic support (FRV) compared with vasopressor-restrictive liberal fluid administration (LFA) on clinically relevant perfusion of the deep inferior epigastric perforator (DIEP) flap via intraoperative indocyanine green (ICG) fluorescence imaging. The primary end point of the study was quantitative assessment of the percentage of insufficiently perfused tissue (NP) on the overall flap. Major complications were assessed as secondary end points. RESULTS In 44 DIEP flap breast reconstructions after mastectomy, FRV circulatory support resulted in no statistically significant difference in total flap perfusion as detected via ICG fluorescence imaging in direct comparison with a traditional LFA strategy (NPFRV, 31.8% ± 12.2% vs NPLFA, 29.5% ± 13.3%; p = 0.559). One flap failure was registered with LFA, whereas no major complication occurred in the FRV cohort. CONCLUSIONS According to the results of this study, neither a norepinephrine concentration of 0.065 ± 0.020 μg/kg/min (FRV) nor fluid administration of 5.1 ± 2.2 ml/kg/h (LFA) has a clinically significant impact on microperfusion in a standard DIEP flap procedure for breast reconstruction. Consistent with the current literature reporting a rise in complications with intraoperative fluid over-resuscitation, one flap failure occurred in the LFA cohort.
Collapse
Affiliation(s)
- Alexandra M Anker
- Center for Plastic, Reconstructive, Aesthetic, and Hand Surgery, University Hospital Regensburg and Caritas Hospital St. Josef Regensburg, Regensburg, Germany.
| | - Lukas Prantl
- Center for Plastic, Reconstructive, Aesthetic, and Hand Surgery, University Hospital Regensburg and Caritas Hospital St. Josef Regensburg, Regensburg, Germany
| | - Catharina Strauss
- Center for Plastic, Reconstructive, Aesthetic, and Hand Surgery, University Hospital Regensburg and Caritas Hospital St. Josef Regensburg, Regensburg, Germany
| | - Vanessa Brébant
- Center for Plastic, Reconstructive, Aesthetic, and Hand Surgery, University Hospital Regensburg and Caritas Hospital St. Josef Regensburg, Regensburg, Germany
| | - Felix Schenkhoff
- Department of Anesthesiology, Caritas Hospital St. Josef Regensburg, Regensburg, Germany
| | - Michael Pawlik
- Department of Anesthesiology, Caritas Hospital St. Josef Regensburg, Regensburg, Germany
| | - Jody Vykoukal
- Department of Clinical Cancer Prevention and The McCombs Institute for the Early Detection and Treatment of Cancer, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Silvan M Klein
- Center for Plastic, Reconstructive, Aesthetic, and Hand Surgery, University Hospital Regensburg and Caritas Hospital St. Josef Regensburg, Regensburg, Germany
| |
Collapse
|
30
|
Thacoor A, Kanapathy M, Torres-Grau J, Chana J. Deep inferior epigastric perforator (DIEP) flap: Impact of drain free donor abdominal site on long term patient outcomes and duration of inpatient stay. J Plast Reconstr Aesthet Surg 2018; 71:1103-1107. [DOI: 10.1016/j.bjps.2018.04.019] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Revised: 03/21/2018] [Accepted: 04/29/2018] [Indexed: 10/16/2022]
|
31
|
Wade RG, Watford J, Wormald JCR, Bramhall RJ, Figus A. Perforator mapping reduces the operative time of DIEP flap breast reconstruction: A systematic review and meta-analysis of preoperative ultrasound, computed tomography and magnetic resonance angiography. J Plast Reconstr Aesthet Surg 2017; 71:468-477. [PMID: 29289500 DOI: 10.1016/j.bjps.2017.12.012] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Revised: 11/17/2017] [Accepted: 12/05/2017] [Indexed: 02/02/2023]
Abstract
BACKGROUND Prior to DIEP flap breast reconstruction, mapping the perforators of the lower abdominal wall using ultrasound, computed tomography angiography (CTA) or magnetic resonance angiography (MRA) reduces the risk of flap failure. This review aimed to investigate the additional potential benefit of a reduction in operating time. METHODS We systematically searched the literature for studies concerning adult women undergoing DIEP flap breast reconstruction, which directly compared the operating times and adverse outcomes for those with and without preoperative perforator mapping by ultrasound, CTA or MRA. Outcomes were extracted, data meta-analysed and the quality of the evidence appraised. RESULTS Fourteen articles were included. Preoperative perforator mapping by CTA or MRA significantly reduced operating time (mean reduction of 54 minutes [95% CI 3, 105], p = 0.04), when directly compared to DIEP flap breast reconstruction with no perforator mapping. Further, perforator mapping by CTA was superior to ultrasound, as CTA saved more time in theatre (mean reduction of 58 minutes [95% CI 25, 91], p < 0.001) and was associated with a lower risk of partial flap failure (RR 0.15 [95% CI 0.04, 0.6], p = 0.007). All studies were at risk of methodological bias and the quality of the evidence was very low. CONCLUSIONS The quality of research regarding perforator mapping prior to DIEP flap breast reconstruction is poor and although preoperative angiography appears to save operative time, reduce morbidity and confer cost savings, higher quality research is needed. REGISTRATION PROSPERO ID CRD42017065012.
Collapse
Affiliation(s)
- Ryckie G Wade
- Department of Plastic and Reconstructive Surgery, Leeds Teaching Hospitals Trust, Leeds, Yorkshire, UK; Faculty of Medicine and Health Sciences, University of Leeds, Leeds, Yorkshire, UK.
| | - James Watford
- Faculty of Medicine and Health Sciences, University of Leeds, Leeds, Yorkshire, UK
| | - Justin C R Wormald
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, UK
| | - Russell J Bramhall
- Department of Plastic and Reconstructive Surgery, Leeds Teaching Hospitals Trust, Leeds, Yorkshire, UK
| | - Andrea Figus
- Department of Surgery, Plastic Surgery and Microsurgery Section, University Hospital, Cagliari, Italy; Department of Surgical Sciences, Faculty of Medicine, University of Cagliari, Italy
| |
Collapse
|
32
|
Heine N, Koch C, Brebant V, Kehrer A, Anker A, Prantl L. Breast sensitivity after mastectomy and autologous reconstruction. Clin Hemorheol Microcirc 2017; 67:459-465. [DOI: 10.3233/ch-179227] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Norbert Heine
- Center of Plastic and Reconstructive Surgery, University Medical Center Regensburg, Germany
| | - Christoph Koch
- Center of Plastic and Reconstructive Surgery, University Medical Center Regensburg, Germany
| | - Vanessa Brebant
- Center of Plastic and Reconstructive Surgery, University Medical Center Regensburg, Germany
| | - Andreas Kehrer
- Center of Plastic and Reconstructive Surgery, University Medical Center Regensburg, Germany
| | - Alexandra Anker
- Center of Plastic and Reconstructive Surgery, University Medical Center Regensburg, Germany
| | - Lukas Prantl
- Center of Plastic and Reconstructive Surgery, University Medical Center Regensburg, Germany
| |
Collapse
|
33
|
Evidence-Based Performance Measures: Quality Metrics for the Care of Patients Undergoing Breast Reconstruction. Plast Reconstr Surg 2017; 140:775e-781e. [PMID: 29176411 DOI: 10.1097/prs.0000000000003845] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The American Society of Plastic Surgeons commissioned the Breast Reconstruction Performance Measure Development Work Group to identify and draft quality measures for the care of patients undergoing breast reconstruction surgery. Two outcome measures were identified. The first desired outcome was to reduce the number of returns to the operating room following reconstruction within 60 days of the initial reconstructive procedure. The second desired outcome was to reduce flap loss within 30 days of the initial reconstructive procedure. All measures in this report were approved by the American Society of Plastic Surgeons Breast Reconstruction Performance Measures Work Group and the American Society of Plastic Surgeons Executive Committee. The Work Group recommends the use of these measures for quality initiatives, Continuing Medical Education, Maintenance of Certification, American Society of Plastic Surgeons' Qualified Clinical Data Registry reporting, and national quality reporting programs.
Collapse
|
34
|
McInerney NM, O'Neill AC, Zhong T, Hofer SOP. Response to "Complications in DIEP Flap Breast Reconstruction after Mastectomy for Breast Cancer: A Prospective Cohort Study Comparing Unilateral and Bilateral Reconstructions". Ann Surg Oncol 2017; 24:561-562. [PMID: 29147926 DOI: 10.1245/s10434-017-6172-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Indexed: 11/18/2022]
Affiliation(s)
- Niall M McInerney
- Division of Plastic and Reconstructive Surgery, Department of Surgery and Surgical Oncology, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Anne C O'Neill
- Division of Plastic and Reconstructive Surgery, Department of Surgery and Surgical Oncology, University Health Network, University of Toronto, Toronto, ON, Canada. Anne.O'
| | - Toni Zhong
- Division of Plastic and Reconstructive Surgery, Department of Surgery and Surgical Oncology, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Stefan O P Hofer
- Division of Plastic and Reconstructive Surgery, Department of Surgery and Surgical Oncology, University Health Network, University of Toronto, Toronto, ON, Canada
| |
Collapse
|
35
|
Wade RG, Razzano S, Sassoon EM, Haywood RM, Wormald JCR, Figus A. Reply to "Complications in DIEP Flap Breast Reconstruction After Mastectomy for Breast Cancer: A Prospective Cohort Study Comparing Unilateral Versus Bilateral Reconstructions". Ann Surg Oncol 2017; 24:563-565. [PMID: 29116492 DOI: 10.1245/s10434-017-6173-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Indexed: 11/18/2022]
Affiliation(s)
- Ryckie G Wade
- Leeds Teaching Hospitals Trust, Leeds, UK.,University of Leeds, Leeds, UK
| | | | | | | | | | - Andrea Figus
- University Hospital, Duilio Casula, Cagliari, Italy. .,University of Cagliari, Cagliari, Italy.
| |
Collapse
|