The Influence of the Superficial Venous System on DIEP Flap Drainage in Breast Reconstruction

BACKGROUND

 Autologous tissue has become the gold standard in breast reconstruction. The use of a deep inferior epigastric perforator (DIEP) flap has the advantages of giving a natural appearance to the reconstructed breast and being associated with lower morbidity at the donor site when compared with the transverse rectus abdominis myocutaneous flap. Venous complications such as venous thrombosis and insufficiency remain the main causes of flap loss and surgical revisions. The aim of this study was to evaluate the influence of superficial venous drainage of the DIEP flap and the addition of a second venous anastomosis have on flap survival.

METHODS

 This was a retrospective cohort study collected from a prospective database maintained by our institution. Data was obtained from the medical records of female patients who underwent mastectomy and breast reconstruction with a DIEP flap between March 2010 and March 2017. We evaluated 137 DIEP patients with unilateral breast reconstructions. In 64 (46.7%) the deep venous system was chosen and 73 (53.3%) had an additional superficial vein anastomosed.

RESULTS

 Out of the 137 patients evaluated, there were 16 (11.67%) cases of revision, 14 (10.21%) were due to venous thrombosis. Twelve cases (8.75%) of flap loss were reported. Reoperation rate was lower in the dual venous drainage group when compared with the single venous drainage group (p = 0.005), as was the rate of flap loss (p = 0.006) and reoperation due to venous thrombosis (p = 0.002). Out of the 125 DIEP flaps, fat necrosis was clinically identified in 7 (5.1%) cases, and the rate was lower in the dual venous drainage system group (p = 0.01).

CONCLUSION

 Dual venous drainage of a DIEP flap appears to reduce the rates of venous thrombosis, reoperation, total flap loss, and fat necrosis.

Alternatives to the Gold Standard: A Systematic Review of Profunda Artery Perforator and Lumbar Artery Perforator Flaps for Breast Reconstruction

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.

Secondary solution for breast reconstruction following total DIEP flap loss: A single-center experience after 3270 DIEP flaps

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.

[Robotic-Assisted DIEP Flap Harvest for Autologous Breast Reconstruction: Case Report, Technical Aspects and Identification of Suitable Patients]

BACKGROUND

Robotic-assisted harvest of the deep inferior epigastric perforator (DIEP) flap is an innovative modification of the traditional open preparation for autologous breast reconstruction. It is assumed that donor-site morbidity (herniae, bulging) is reduced by minimising the fascial incision length in robotic-assisted DIEP flap harvest.

MATERIAL & METHODS

This is the first report of a robotic-assisted DIEP harvest in Germany, which was performed in April 2023 at the University Hospital of Freiburg in an interdisciplinary approach of the Departments of Plastic Surgery, Urology and Gynaecology. To determine the value of this novel technique, we assessed the demand by retrospectively performing an analysis of potential patients and conducted a cost analysis based on the breast reconstructions with DIEP flap harvest performed between April 2021 and May 2023 at the Department of Plastic Surgery at Freiburg University Hospital. To this end, we carried out a retrospective analysis of preoperative CT angiographies to determine the proportion of patients suitable for a robotic-assisted procedure in a post-hoc analysis. Furthermore, we describe the basic robotic-assisted techniques and discuss the TEP and TAPP laparoscopic approaches.

RESULTS

In line with the previously published literature, a short intramuscular course (≤25 mm) and a perforator diameter of≥1.5 mm and≥2.7 mm (subgroup) were defined as a crucial condition for the robotic-assisted procedure. We analysed 65 DIEP flaps harvested in 51 patients, of which 26 DIEP flaps in 22 patients met both criteria, i. e.≤25 mm intramuscular course and≥1.5 mm diameter of the perforator, while 10 DIEP flaps in 10 patients additionally met the criteria of the subgroup (≥2.7 mm diameter). Based on the intramuscular course of the perforators in the CT angiographies of those 26 DIEP flaps, a potential reduction of the fascial incision of 96.8±25.21 mm (mean±standard deviation) compared with the conventional surgical approach was calculated. The additional material costs in our case were EUR 986.01. However, ischaemia time was 33,5 minutes longer than the median of the comparative cohort.

CONCLUSION

The robotic-assisted procedure has already proven to be a feasible alternative in a suitable patient population. However, further studies are needed to confirm that robotic-assisted DIEP flap harvest actually reduces harvest site morbidity and thereby justifies the additional costs and complexity.

Continuing Insurance Coverage for Flap-Based Breast Reconstruction: Is There a Reservation Cost Related to a Woman's Abdominal Flap Choice?

BACKGROUND

The recent proposed alterations to the Centers for Medicare and Medicaid Services regulations, although subsequently reversed on August 21, 2023, have engendered persistent concerns regarding the impact of insurance policies on breast reconstruction procedures coverage. This study aimed to identify factors that would influence women's preferences regarding autologous breast reconstruction to better understand the possible consequences of these coverage changes.

METHODS

A survey of adult women in the United States was conducted via Amazon Mechanical Turk to assess patient preferences for breast reconstruction options, specifically deep inferior epigastric perforator (DIEP) and transverse rectus abdominis myocutaneous (TRAM) flap surgery. The Cochrane-Armitage test evaluated trends in flap preferences concerning incremental out-of-pocket payment increases.

RESULTS

Of 500 total responses, 485 were completed and correctly answered a verification question to ensure adequate attention to the survey, with respondents having a median (interquartile range) age of 26 (25-39) years. When presented with the advantages and disadvantages of DIEP versus TRAM flaps, 78% of respondents preferred DIEP; however, as DIEP's out-of-pocket price incrementally rose, more respondents favored the cheaper TRAM option, with $3804 being the "indifference point" where preferences for both procedures converged (P < 0.001). Notably, respondents with a personal history of breast reconstruction showed a higher preference for DIEP, even at a $10,000 out-of-pocket cost (P = 0.04).

CONCLUSIONS

Out-of-pocket cost can significantly influence women's choices for breast reconstruction. These findings encourage a reevaluation of emergent insurance practices that could potentially increase out-of-pocket costs associated with DIEP flaps, to prevent cost from decreasing equitable patient access to most current reconstructive options.

Inset techniques for the DIEP flap - what improves aesthetic outcomes?

INTRODUCTION

The deep inferior epigastric perforator (DIEP) flap is widely considered as the gold standard in breast reconstruction. The inset technique of the DIEP flap is crucial in determining the overall aesthetic outcome; however, to date no systematic review is available that comprehensively assesses the various techniques. Evaluation of topic: A systematic review was performed according to the PRISMA guidelines. The methodology is outlined within our published protocol (Prospero CRD42023449477). Included articles met a minimal criterion compromising of the intervention (DIEP free flap for breast reconstruction) and outcomes (aesthetic and clinical outcomes). Six articles were included in this review, with a total of 346 patients and a follow-up ranging from 6 months to 4 years. Four articles were of a prospective case series study design, one article was a randomized controlled trial, and one article was a case-control study. The risk of bias was assessed to be high in the case series, but low and moderate in the randomized controlled trial and case-control study respectively.

CONCLUSION

Although limited by the quality of the evidence, the single aesthetic unit principle, dual-plane inset, elimination of the need for a skin paddle, appropriate flap positioning and rotation, and algorithmic in-setting may all improve the aesthetic outcome of DIEP free flaps.

Surgical Outcomes of Autologous Breast Reconstruction in Low Body Mass Index Patients: Beyond the Standard DIEP Flap

BACKGROUND

Autologous breast reconstruction provides higher satisfaction than implant-based reconstruction in women with low body mass index (BMI). However, the accepted standard of microvascular breast reconstruction, the deep inferior epigastric perforator (DIEP) flap, can be challenging to achieve due to the paucity of adnominal bulk in these patients. This study compared operative outcomes in women with BMI less than 23.5 following reconstruction after one of three free flap methods: the DIEP flap, alternative flaps (ie, lumbar artery perforator flap or profounda artery perforator flap), and stacked flaps.

METHODS

A retrospective study was conducted on thin patients (BMI <23.5) who underwent autologous breast reconstruction between 2010 and 2021 by two senior authors (N.T.H. and S.S.T.) at a single institution. One hundred fifteen patients were divided into three reconstructive groups. Flap weights, complication rates, secondary revisions, and fat grafting in each group were then compared.

RESULTS

The success rate in all three groups was 100%, with only one partial flap loss in the stacked group. There was a significant difference in overall minor complications and donor complications among the three groups, with alternative flaps experiencing the most. All three groups had similar incidences of recipient breast complications, medical complications, need for secondary revisions, and amount of fat grafted.

CONCLUSIONS

Autologous breast reconstruction in low BMI patients yields successful and durable results. This study shows that predictable results in the thin patient population can be obtained via alternate autologous methods beyond the standard DIEP flap.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

The third dimension in perforator mapping-Comparison of Cinematic Rendering and maximum intensity projection in abdominal-based autologous breast reconstruction

BACKGROUND

Cinematic Rendering (CR) is a recently introduced post-processing three-dimensional (3D) visualization imaging tool. The aim of this study was to assess its clinical value in the preoperative planning of deep inferior epigastric artery perforator (DIEP) or muscle-sparing transverse rectus abdominis myocutaneous (MS-TRAM) flaps, and to compare it with maximum intensity projection (MIP) images. The study presents the first application of CR for perforator mapping prior to autologous breast reconstruction.

METHODS

Two senior surgeons independently analyzed CR and MIP images based on computed tomography angiography (CTA) datasets of 20 patients in terms of vascular pedicle characteristics, the possibility to harvest a DIEP or MS-TRAM flap, and the side of the flap harvest. We calculated inter- and intra-observer agreement in order to examine the accordance of both image techniques.

RESULTS

We observed a good inter- and intra-observer agreement concerning the type of flap and the side of the flap harvest. However, the agreement on the pedicle characteristics varies depending on the considered variable. Both investigators identified a significantly higher number of perforators with MIP compared with CR (observer 1, p<0.0001 and observer 2, p<0.0385).

CONCLUSION

The current study serves as an explorative study, showing first experiences with CR in abdominal-based autologous breast reconstruction. In addition to MIP images, CR might improve the surgeon's understanding of the individual's anatomy. Future studies are required to compare CR with other 3D visualization tools and its possible effects on operative parameters.

Impact of body mass index on free DIEP flap breast reconstruction: A multicenter cohort study

INTRODUCTION

Several patient-related factors have been identified with regard to the safety and efficacy of breast reconstructions. This study analyzed the largest series of microsurgical breast reconstructions in Germany using deep inferior epigastric perforator (DIEP) flaps, with a focus on the impact of patient body mass index (BMI).

PATIENTS AND METHODS

A total of 3911 female patients underwent 4561 free DIEP flap breast reconstructions across 22 different centers. The cases were divided into five groups using World Health Organization BMI criteria: underweight group (BMI <18.5 kg/m²), normal weight/ control group (BMI: 18.5-24.9 kg/m²), overweight group (BMI: 25-29.9 kg/m²), moderately obese group (BMI: 30-34.9 kg/m²), and severely obese group (BMI ≥ 35 kg/m²). Surgical complications were accounted for and the five BMI groups were then compared.

RESULTS

Overall, there was no significant difference regarding the rate of partial- and total flap loss between all BMI groups (p > 0.05). However, overweight and obese patients showed significantly higher rates of postoperative infections at the donor and recipient sites than the control group (donor site infections: overweight 0.6%; moderately obese 0.9%; severely obese 2.4% vs control 0.1%; all p<0.01; recipient site infections: overweight 0.5%; moderately obese 0.8%; severely obese 1.4% vs control 0.1%; all p < 0.05). The rate of medical complications also differed significantly between groups, with the highest rates in moderately and severely obese women (moderately obese: 8.4%; severely obese: 13.0% vs. control: 5.1%; p < 0.01).

CONCLUSION

Our findings suggest that successful free tissue transfer can be achieved even in an underweight and severely obese population with acceptable risk for complications.

Immediate breast reconstruction after salvage mastectomy: Case control outcome comparisons of DIEP flap and DTI reconstruction

BACKGROUND

Cancer recurrence after breast-conserving therapy is most often managed by salvage mastectomy. Successful breast reconstruction immediately after salvage mastectomy, however, remains challenging because the reconstruction is performed on previously irradiated breast tissue.

METHODS

Records of patients who underwent breast reconstruction from June 2010 to June 2019 were reviewed, including their demographic characteristics, methods of breast reconstruction, and early and late outcomes. Deep inferior epigastric perforator (DIEP) flaps and direct-to-implant (DTI) reconstructions following salvage mastectomies were compared with reconstructions following completion or primary mastectomies. Patients who underwent reconstruction followed by postmastectomy radiotherapy (PMRT) and patients followed up for less than 6 months were excluded.

RESULTS

DIEP flaps in 27 breasts that underwent salvage mastectomy were compared with DIEP flaps in 32 breasts that underwent completion and 564 that underwent primary mastectomy. Rates of early complications, including microsurgical revision and total flap loss, and of late complications (>6 months after surgery), including fat necrosis and flap volume loss, did not differ significantly. DTI reconstruction in 20 breasts that underwent salvage mastectomy was compared with DTI reconstruction in 12 breasts that underwent completion and 351 that underwent primary mastectomy. Wound healing problems, including wound dehiscence and delayed wound healing (15% vs. 2.6%, P = 0.0022), and capsular contracture (30% vs. 5.4%, P = 0.0000), were significantly more frequent in breasts that underwent salvage than primary mastectomy.

CONCLUSIONS

DIEP flap is a successful reconstruction option after salvage mastectomy. DTI reconstruction is associated with higher rates of wound healing problems and capsular contracture after salvage than after primary mastectomy.

Effect of Simvastatin Use in Free Tissue Transfer: An Experimental Study in a Rat Epigastric Free Flap Model

BACKGROUND

 Statins are traditionally used in lowering cholesterol and low-density lipoprotein biosynthesis, but recent reports show their beneficial effect on microcirculation. The aim of this study was to investigate the effect of simvastatin on the microcirculation and in conjunction with aspirin in a rat free epigastric flap model.

METHODS

 Thirty-six Sprague-Dawley rats were divided into group A (control, n = 12), group B (simvastatin treated, n = 12), and group C (simvastatin and aspirin, n = 12). Bilateral free epigastric skin flap was used to evaluate the effect. At 48 hours, flaps biopsies were evaluated for inflammatory activity, nitric oxide content, and thrombomodulin regulation in the endothelial lining of microvessels. Flap survival was evaluated on day 7.

RESULTS

 The diameter of microvessels and nitric oxide activity in groups B and C were significantly higher than in group A (p < 0.005 and 0.015, respectively). The perivascular inflammatory cell infiltrates and intravascular adhesions were predominant in group A compared with groups B and C (p < 0.005). Groups B and C demonstrated significant higher degree of thrombomodulin expression. The flap survival rate on day 7 was 70.8% for group A, and 87.5% and 91.7%, respectively, for groups B and C without significance between the two (p = 0.675).

CONCLUSION

 Simvastatin significantly improves the free flap survival by effective anti-inflammatory, vasodilator, and anticoagulant activities. Combined therapy did not have an antagonistic effect and further study is needed to see synergistic action through different mechanisms.

Deconstructing the Reconstruction: Evaluation of Process and Efficiency in Deep Inferior Epigastric Perforator Flaps

BACKGROUND

With advances in technology and technique, the goal of microvascular breast reconstruction has transitioned from flap success to minimizing complications and maximizing aesthetic outcome and efficiency. In an effort to evaluate efficiency, the authors implemented a rigorous process analysis in their practice to evaluate deep inferior epigastric perforator (DIEP) flap breast reconstruction.

METHODS

A prospective implementation of process analysis was instituted on 147 DIEP flaps. The eight critical maneuvers for a DIEP flap are (1) skin to perforator identification, (2) perforator decision making, (3) perforator dissection, (4) pedicle dissection, (5) flap harvest, (6) preparation for microsurgery, (7) venous anastomosis, and (8) arterial anastomosis. Surgeons with variable experiences (faculty, faculty with senior resident/fellow, and supervised chief resident) used these eight steps to perform DIEP flap reconstruction. The outcomes and time of each maneuver were tracked.

RESULTS

The total flap harvest time among the three groups was 54.8 minutes for faculty surgeons, 98.3 minutes for senior resident/fellow working with faculty, and 178.8 minutes for supervised chief resident (p < 0.001). The largest difference was seen in perforator dissection. Increasing the number of perforators resulted in longer flap harvest times. Perforator location did not have an impact on times, but harvesting multiple rows took longer for less experienced surgeons. Body mass index and flap weight did not have an impact on time.

CONCLUSIONS

The authors share their experience using process analysis for DIEP flap reconstruction. They defined eight critical maneuvers to maximize efficiency and safety. By communicating efficient processes and integrating them into the workflow of a given operation, surgeons can continue to improve throughout the arc of their careers.

CTA in preoperative planning for DIEP breast reconstruction: what the reconstructive surgeon wants to know. A modified Delphi study

AIM

To gather expert reconstructive surgical opinion to define and rank the surgically most important anatomy and provide guidance for report content to radiologists when reading a preoperative computed tomography angiography (CTA).

MATERIALS AND METHODS

A modified Delphi approach was used, involving a panel of 13 microsurgery experts across North America. Data from three consecutive online surveys were collected and returned to the respondents in the subsequent survey, allowing each respondent to see the range of opinions from other field experts.

RESULTS

Response rates were 62%, 77%, and 69% for each of the three survey rounds, respectively. The panel identified that the most important perforator characteristics in selecting the optimal perforator are diameter of the vein, perforator location within the flap, and diameter of the artery, respectively. The stated preference was for perforators located below the umbilicus. If no suitable perforator was located below the umbilicus, the panel would consider perforators up to 2 cm above the umbilicus. The most important considerations for the preoperative radiology planning report are: the size of the perforator vein, perforator location relative to landmarks, and the size of the perforator artery.

DISCUSSION

Based on the panel of expert reconstructive microsurgeons, the most surgically important anatomical considerations to be assessed and included in preoperative CTA reports for DIEP flap breast reconstruction were determined. The recommendations for reporting of preoperative DIEP breast reconstructions are presented, which, in consultation with local surgeons, can be used to form a template for reporting.

The originating pattern of deep inferior epigastric artery: anatomical study and surgical considerations

PURPOSE

Studies focusing on the originating patterns of the deep inferior epigastric artery (DIEA) have not been conducted. Here, we analyzed the vascular anatomy of the DIEA with computed tomographic angiography (CTA) to provide assistance during proximal pedicle dissection of a DIEA-based flap.

METHODS

We conducted a retrospective study on patients who had undergone breast reconstruction with the transverse rectus abdominis musculocutaneous flap and the deep inferior epigastric perforator flap from March 2006 to October 2016. Preoperative three-dimensional computed tomographic angiograms of the abdominal wall (hemi-abdominal walls) were employed in this study, and three independent surgeons reviewed all CTA images. The originating angles and the distance from the originating point to the DIEA turning point were analyzed. Moreover, we assessed the relationship between the measured values and patients' characteristics, such as abdominal surgery history.

RESULTS

CTA data of 184 patients and 368 hemiabdomens were reviewed and analyzed. Most of the DIEAs originated from the external iliac artery in the medial direction, proceeded caudally, and curved in a cephalic direction. The average descending length was 11.29 mm. As the DIEA origin angle decreased (toward the caudal direction), the distance of the initial descent increased (r = 0.382, p < 0.01). In addition, the descending length was significantly larger (p < 0.01) in the operation group (12.22 mm) than in the non-operation group (9.86 mm).

CONCLUSIONS

Surgeons should consider DIEA-originating patterns to ensure safe pedicle dissection during flap elevation.

Laparoscopy-assisted Chimeric Peritoneal-deep Inferior Epigastric Perforator Flap for Reconstruction of Hand and Foot

Management of hand and foot defects with exposed tendons is a big challenge for plastic surgeons. Thin vascularized tissue offers an ideal surface for tendon excursion.

OBJECTIVE

This study examines the reconstructive benefits of a laparoscopy-assisted chimeric peritoneal-deep inferior epigastric artery perforator (DIEP) flap in the treatment of hand and foot injury defects.

MATERIALS AND METHODS

A retrospective review was performed on 8 patients (6 men, 2 women) that received hand or foot reconstruction with laparoscopy-assisted chimeric peritoneal-DIEP flap. Soft tissue defects of the hand or foot ranged from 16 cm x 10 cm to 22 cm x 14 cm. The peritoneum supplied by the peritoneal branches of the deep inferior epigastric artery was retrieved by laparoscopy to cover exposed extensor tendons, while the DIEP flap consisted of the cutaneous component part of this chimeric flap.

RESULTS

The flaps survived in 7 of 8 patients. Partial necrosis of the chimeric flap was observed in 1 patient due to venous thrombosis. A split-thickness skin graft then was performed to achieve wound closure on that patient. Motor and sensory functions of these 8 patients improved gradually within the first-year follow-up.

CONCLUSIONS

The laparoscopy-assisted chimeric peritoneal-DIEP flap is useful for reconstructing defects of the hand and foot with exposed tendons.

Complications and Patient-Reported Outcomes after Abdominally Based Breast Reconstruction: Results of the Mastectomy Reconstruction Outcomes Consortium Study

BACKGROUND

Abdominal flap reconstruction is the most popular form of autologous breast reconstruction. The current study compared complications and patient-reported outcomes after pedicled transverse rectus abdominis myocutaneous (TRAM), free TRAM, deep inferior epigastric perforator (DIEP), and superficial inferior epigastric artery (SIEA) flaps.

METHODS

Patients undergoing abdominally based breast reconstruction at 11 centers were prospectively evaluated for abdominal donor-site and breast complications. Patient-reported outcomes were measured by the BREAST-Q and Patient-Reported Outcomes Measurement Information System surveys. Mixed-effects regression models were used to assess the effects of procedure type on outcomes.

RESULTS

Seven hundred twenty patients had 1-year follow-up and 587 had 2-year follow-up. Two years after reconstruction, SIEA compared with DIEP flaps were associated with a higher rate of donor-site complications (OR, 2.7; p = 0.001); however, SIEA flaps were associated with higher BREAST-Q abdominal physical well-being scores compared with DIEP flaps at 1 year (mean difference, 4.72, on a scale from 0 to 100; p = 0.053). This difference was not significant at 2 years. Abdominal physical well-being scores at 2 years postoperatively were lower in the pedicled TRAM flap group by 7.2 points (p = 0.006) compared with DIEP flaps and by 7.8 points (p = 0.03) compared with SIEA flaps, and in the free TRAM flap group, scores were lower by 4.9 points (p = 0.04) compared with DIEP flaps. Bilateral reconstruction had significantly lower abdominal physical well-being scores compared with unilateral reconstruction.

CONCLUSIONS

Although all abdominally based flaps are viable breast reconstruction options, DIEP and SIEA flaps are associated with higher abdominal physical well-being than pedicled and free TRAM flaps. Although SIEA flaps offer the advantage of not violating the fascia, higher rates of donor-site complications may diminish patient satisfaction.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, II.

Meta-analysis of flap perfusion and donor site complications for breast reconstruction using pedicled versus free TRAM and DIEP flaps

OBJECTIVES

The transverse rectus abdominis musculocutaneous (TRAM) flap is an important option for breast reconstruction. Several studies have recently evaluated whether a greater number of complications result from the use of pedicled TRAM (pTRAM) flaps versus either free TRAM (fTRAM) flaps or deep inferior epigastric artery perforator (DIEP) flaps. To clarify the evidence regarding this issue, we performed an objective meta-analysis of published studies.

MATERIALS AND METHODS

A literature search of articles published between January 1, 1990, to January 1, 2017 was performed using the PubMed, EMBASE, Scopus, and Cochrane databases. Heterogeneity was statistically analyzed, and fixed effects and random effects models were used as appropriate.

RESULTS

Eleven articles comparing pedicled TRAM (pTRAM) flaps with either free TRAM (fTRAM) or DIEP flaps were included. The articles evaluated a total of 3968 flaps, including 1891 pTRAM flaps, 866 fTRAM flaps, and 1211 DIEP flaps. Patients with fTRAM flaps had a significantly lower risk of fat necrosis and partial flap necrosis than those with pTRAM flaps. No difference was observed in total flap necrosis and hernia or bulge between fTRAM and pTRAM flaps. No difference was noted in flap complications between DIEP and pTRAM flaps except for hernia or bulge..

CONCLUSION

Although pTRAM flaps are being replaced by fTRAM and DIEP flaps, which exhibit fewer complications related to flap ischemia and donor site morbidity, it was unclear from the literature which flap type was most beneficial regarding flap vascularity and donor site morbidity. Hence, surgeons should choose the appropriate option based on their preferences and on patient factors..

Use of both antegrade and retrograde internal mammary vessels in the bipedicled deep inferior epigastric perforator flap for unilateral breast reconstruction

BACKGROUND

Autologous abdominal tissue transfer is a well-established method of breast reconstruction. The deep inferior epigastric perforator (DIEP) flap has the additional benefit of minimal donor site morbidity as it spares the muscle and fascia. Conventional DIEP flaps may not provide adequate volume in cases where the patient is thin, has midline abdominal scars, and/or has a large volume of tissue to replace. One solution is to use a bipedicled DIEP flap, incorporating all the available abdominal tissue. Bipedicled DIEP flaps have been described in a number of different configurations. The literature appears to favor intra-flap anastomosis, with a minimal exposition of two recipient vessels. It has been demonstrated that both the antegrade internal mammary artery (aIMA) and retrograde internal mammary artery (rIMA) are adequate recipient vessels. Here, the authors present a single-center experience with bipedicled DIEP flaps to both the aIMA and rIMA, showing their feasibility and safety.

METHODS

A retrospective review of patients who underwent unilateral breast reconstruction using bipedicled DIEP flaps was performed to assess outcomes.

RESULTS

A total of 20 patients who underwent unilateral breast reconstruction using a bipedicled DIEP flap were selected for this study. All of them were previously diagnosed with cancer. There were zero flap failure and zero instance of abdominal hernia or issue with abdominal wall functionality following the surgeries.

CONCLUSIONS

The series of surgeries described in this study resulted in successful breast reconstruction in 20 women using a bipedicled DIEP flap. The results show that this approach allows for reconstruction in places where a conventional DIEP does not provide adequate volume, achieved safely, and does not increase morbidity. The bipedicled DIEP flap is a viable option for large-volume autologous breast reconstruction, providing ample tissue for successful reconstruction while also allowing for shorter recovery and limited donor site morbidity.

TRIDIMENSIONAL DOPPLER ASSESSMENT: A RELIABLE, NON-INVASIVE AND COST-EFFECTIVE METHOD FOR PREOPERATIVE PERFORATOR ASSESSMENT IN DIEP FLAP

BACKGROUND

The preoperative perforator mapping is an important step in autologous breast reconstruction, making the flap raising safer, more predictable and time-saving. Although the Doppler exam has proven to be less accurate in locating perforators compared with colour duplex sonography and CTA, it will probably remain of importance in clinical practice. The aim of this paper is to share some advices on how to perform a Doppler exam in preoperative evaluation of a DIEAp flap, increasing its reliability in location of the perforators.

METHODS

The study was carried-out preoperatively on 26 consecutive patients. For the evaluation of the matching between Doppler Dot and operative finding was used a Cartesian coordinate systemResults: We have marked preoperatively 145 perforators in 26 patients for a total of 52 semi-abdomens. An average of 5.6 vessels per patient were marked. Of these, 80 (55.17%) were found between 0-1 cm, 36 (24.82%) between 1-2 cm and 5 (3.4%) of these more than 2 cm from each other. We had 24 (16.55%) false positives in which there was no correspondence between the signal and the intraoperative finding.

CONCLUSION

Although the Doppler exam may not provide the same anatomic details as the other newer modalities, such as CTA and MRA, the HHD remains a very useful and important tool for autologous reconstruction. We recommend performing this exam in our standardized and reproducible method to improve the reliability..

[Application of free chimeric perforator flap with deep epigastric inferior artery for the soft tissue defect on the lower extremity with deep dead space]

OBJECTIVE

To explore the feasibility and the effect of free chimeric perforator flap with deep inferior epigastric artery for the soft tissue defect on the lower extremity with deep dead space.

METHODS

From Mar. 2010 to Aug. 2011, 8 patients with soft tissue defects on the lower extremities combined with dead space, bone or joint exposure were reconstructed with free hinged perforator flaps with deep inferior epigastric artery. The muscle flap was inserted into the deep dead space, with perforator flap for superficial defect. The defects on the donor sites were closed directly.

RESULTS

All the flaps survived with primary healing. Good color and texture was achieved. The patients were followed up for 12-24 months, with an average of 16 months. 2 over-thick flaps were treated by flap-thinning surgery. Only linear scar was left on the donor site on abdomen with no malfunction.

CONCLUSIONS

The free chimeric perforator flap with deep inferior epigastric artery can simultaneously construct the dead space and superficial defect with only anastomosis of one set of vascular pedicle. It is an ideal method with good results on recipientsites and less morbidity on donor sites.

Augmented SIEA flap for microvascular breast reconstruction after prior ligation of bilateral deep inferior epigastric arteries

The superficial inferior epigastric artery (SIEA) flap is an excellent option for free tissue transfer breast reconstruction. Similar to the free transverse rectus myocutaneous (TRAM) and deep inferior epigastric perforator (DIEP) flaps, the SIEA pedicle supplies the fasciocutaneous tissues of the lower abdomen. The SIEA flap does not involve removal of or potential damage to the rectus muscles. Nonetheless, the vascular pedicle may be a challenge to dissect and variable in its presence and caliber. This article presents a case report and an extended delay technique to augment the SIEA system in a patient with prior bilateral deep inferior epigastric artery ligation.

Breast reconstruction with autologous tissue--our clinical experience

INTRODUCTION

Breast reconstruction after mastectomy gained new grounds since the introduction of autologous tissue and oncoplastic surgery techniques. Nowadays large postoperative breast defects can be treated with high quality tissues obtained by autogenous flap surgery, to achieve the best functional and physical results.

OBJECTIVES

The purpose of this study is to analyze our results in breast reconstruction using autologous tissue and to emphasize the importance of a multidisciplinary team.

MATERIAL AND METHODS

During a five year period (2005-2009) we performed 28 breast reconstructions after cancer surgery, 15 in delayed and 13 in primary reconstruction, using three types of flaps: latissiumus dorsi flap, transverse rectus abdominis myocutaneous flap and deep inferior epigastric artery perforator flap.

RESULTS

Functional and cosmetic results were very good, only minor complications such as seroma and hematoma of the donor site and partial/marginal flap necrosis occurred after the surgical procedure. There were no major complications like total flap loss.

CONCLUSIONS

Breast reconstruction with autologous tissue is a safe, well proved, although not easy procedure that confers best functional and cosmetic results and is at the same time oncologically safe.

[Vaginal reconstruction with pedicled deep inferior epigastric perforator flap]

OBJECTIVE

To explore a new surgical procedure for vaginal reconstruction with pedicled deep inferior epigastric perforator (DIEP) flap.

METHODS

Since June 2007, 6 cases underwent vaginal reconstruction, including five congenital vaginal absence and one immediately after total vaginal resection due to carcinoma. Intensive CT scans were performed preoperatively for perforator selection. The DIEP flaps were designed vertically on the anterior abdominal wall and transferred for vaginal reconstruction.

RESULTS

All the patients recovered uneventfully with no flap loss and other complication. The patients were followed up for 1 to 8 months (mean, 4 months) with satisfactory results.

CONCLUSION

Vaginal reconstruction with vertical DIEP flaps is a safe and reliable method.

[Application of computed tomography angiography in preoperative design of deep inferior epigastric artery perforator flap]

OBJECTIVE

To explore the application of computed tomography angiography (CTA) in preoperative design of deep inferior epigastric artery perforator (DIEAP) flap.

METHODS

From Jan, 2007 to Mar, 2008, preoperative CTA of deep inferior epigastric artery was performed in 13 patients, including 5 patients with congenital absence of the vagina, 4 patients with penile and scrotal Paget's disease and 4 patients after mastectomy. The images were analyzed, including multiple planar reformation (MPR), maximum intensity projection (MIP) and volume rendering (VR). Then the distributions, branches and locations of perforators of deep inferior epigastric artery were measured. The images from CTA were compared with intraoperative observation.

RESULTS

The images demonstrated the distributions of deep inferior epigastric artery and locations of its perforators, which were proved to be true by intraoperative observation.

CONCLUSIONS

The preoperative CTA of deep inferior epigastric artery is very useful for preoperative design of DIEAP flaps.

[Clinical application of intensive CT in pedicled deep inferior epigastric perforator flap design]

OBJECTIVE

To explore the effect of the intensive CT on the deep inferior epigastric perforator (DIEP) flap design strategy.

METHODS

From June 2007 to March 2008, 7 patients received reconstructive operation of the vertical DIEP flap, among whom there were 5 females with congenital absence of vagina and 2 males with peno-scrotal Paget's disease, aged 18-62 years old. Before the operation, the intensive CT scans were applied to all the patients in search for DIEP. The flaps were designed according to the radiological findings. The scrotum and penis defects were reconstructed in 2 cases and vaginal reconstruction was performed in 5 cases. The flap dimension ranged from 15 cm x 7 cm to 22 cm x 5 cm. The donor site was closed directly.

RESULTS

A total of 10 ideal perforating branches of all the 7 DIEP flaps were found before the operation, with the diameter of over 1.5 mm. Of the 7 flaps, 4 had 1 perforating branch and the other 3 had 2 perforating branches. All 7 flaps survived completely. The incisions of 6 patients obtained healing by first intention. Only 1 patient with Paget's disease had erosion at the scrotum incision and partial necrosis 7 days after the operation, and then healed after discontinuous dressing change. The incisions at the donor site obtained healing by first intension. Two patients complained about draw-off at the lower abdomen on the operated side, which was basically relieved at 7 days after the operation. All patients were followed up for 1 to 10 months (4.5 months on average). No operation-related complication was observed after operation. Six patients were satisfied with the reconstructive results. Only 1 patient was dissatisfied with the buried pennies and requested a revision.

CONCLUSION

The intensive CT scans play an important role in the DIEP flap design. It can not only make the flap safer, but also decrease operation time and improve efficiency.

[Free deep inferior epigastric artery perforator flap techniques for the immediate post modified radial mastectomy reconstruction]

OBJECTIVE

To discuss the feasibility and method of immediate breast reconstruction right after modified radical mastectomy in early breast carcinoma patients.

METHODS

Deep inferior epigastric artery perforation flaps were immediately applied on patients to reconstruct the breast after the skin-sparing mastectomy. The breasts were shaped after the deep inferior epigastric artery and vein were anastomosed to the thoracodorsal artery and vein.

RESULTS

In 10 cases of breast reconstruction by DIEP flaps since 2005, there were completely survival in 8 flaps, distal skin necrosis in 1 flap, adiponecrosis in 1 flap. With the follow-up of 9-28 months, the reconstructed breasts were well-shaped and there were no abdominal complication in dnor sites. Ninety percent patients were satisfied with the results from the good to the best level.

CONCLUSION

Most patients were satisfied with the results of mastectomy reconstruction.

Preoperative imaging for DIEA perforator flaps: a comparative study of computed tomographic angiography and doppler ultrasound

BACKGROUND

Abdominal donor-site flaps, including the transverse rectus abdominis musculocutaneous (TRAM) and deep inferior epigastric artery (DIEA) perforator flaps, are standard in autologous breast reconstruction. With significant variation in the vascular anatomy of the abdominal wall, preoperative imaging is essential for preoperative planning and reducing intraoperative error. Doppler and color duplex sonography have been used with varying results, and the quest continues for optimal preoperative assessment. Computed tomographic angiography has recently been proposed as a noninvasive modality for this purpose. This is the first study to formally compare preoperative Doppler ultrasound with computed tomographic angiography for imaging the DIEA.

METHODS

Eight consecutive patients undergoing DIEA perforator flap surgery for breast reconstruction underwent both computed tomographic angiography and Doppler ultrasound preoperatively. All investigations and procedures were performed at the same institution with the same primary and assisting surgeons and the same radiology team.

RESULTS

Computed tomographic angiography was superior to Doppler ultrasound at identifying the course of the DIEA and its branching pattern, and in visualizing its perforators. Preoperative computed tomographic angiography was highly specific (100 percent) and more sensitive in mapping and visualizing perforators (p = 0.0078). It was also proficient at identifying the superficial epigastric arterial system and for effectively displaying the results intraoperatively. It was substantially quicker and removed the interobserver error associated with Doppler ultrasonography. The study was ceased after eight patients because of the overwhelming benefit of computed tomographic angiography over Doppler ultrasonography.

CONCLUSION

Computed tomographic angiography is a valuable imaging modality for the preoperative assessment of the donor-site vascular supply for TRAM and DIEA perforator flaps.

The use of the inferior epigastric artery for accessory lower polar artery revascularization in live donor renal transplantation

PURPOSE

This study describes the surgical technique and outcomes of live donor renal allografts with multiple arteries in which the lower polar artery was anastomosed to the inferior epigastric artery after declamping.

MATERIALS AND METHODS

Between 1988 and 2004, 477 consecutive live donor renal transplants were performed, including 429 with single and 48 with multiple arteries. Anastomosis of the lower polar artery to the inferior epigastric artery was used for 15 grafts with multiple arteries.

RESULTS

Successful revascularization of all areas of the transplanted graft was confirmed by Doppler ultrasonography in most patients and radionuclide renal scanning +/- MRA in some patients.

CONCLUSIONS

In live donor renal transplantation with multiple arteries, the anastomosis of the lower polar artery to the inferior epigastric artery after declamping avoids prolongation of the ischemia time that occurs with other surgical and microsurgical techniques of intracorporeal and ex vivo surgeries.

The Deep Inferior Epigastric Artery: Anatomy and Applicability as a Source of Microvascular Arterial Grafts

BACKGROUND

Arterial grafts are superior to venous grafts when used for microvascular grafting procedures. Advantages of arterial grafts include anatomical taper, improved size match, improved handling characteristics, and superior patency rates. The deep inferior epigastric artery may be used as a source of microvascular graft to replace damaged or diseased arterial segments. By studying cadaver dissections, it is possible to estimate the clinically usable length and caliber of the deep inferior epigastric artery.

METHODS

Thirty-four preserved cadavers were dissected and 63 deep inferior epigastric arterial systems were removed and measured. The deep inferior epigastric artery was used as an arterial conduit to bypass across nine wrists in eight patients.

RESULTS

The mean length from the external iliac artery to the point at which the vessel displayed an external diameter of 1 mm was 14.06 +/- 2.54 cm. The deep inferior epigastric artery has been used in nine clinical cases as an arterial conduit to bypass distal to the wrist. All nine bypasses were patent 1 year postoperatively, without donor-site complication.

CONCLUSION

The deep inferior epigastric artery is a morphologically reliable and clinically useful source of arterial grafts.

[Applied anatomy of inferior epigastric artery in coronary artery bypass grafting]

OBJECTIVE

To measure the inferior epigastric artery(IEA),coronary artery and arterial bridge to supply the anatomic and hemodynamic data of IEA in coronary artery bypass grafting for clinicians.

METHODS

Anatomic method was adopted to measure the length of IEA, arterial bridge, the outer diameter of IEA and coronary arteries. Colour doppler ultrasound instrument was adopted to measure the caliber and the blood flow rate of IEA and coronary artery.

RESULTS

In the anatomic method, the length of IEA was (13.00+/-2.58)cm and the caliber of original IEA was (2.95+/-0.21)mm, the caliber of IEA intersecting with abdomen rectus was (2.51+/-0.32)mm, and (1.60+/-0.26)mm at 1.0 cm below the umbilicus. In color doppler ultrasound method, the caliber of original IEA was (2.98+/-0.37)mm, and at 5 cm from the original spot was (2.60+/-0.27)mm. The blood flow rate was (57.00+/-6.78)cm/s. The main stem caliber of the left coronary artery was (4.90+/-0.76)mm, and that of the right coronary artery was (3.58+/-0.63)mm; the blood flow rate was (48.50+/-7.72)cm/s. The length of the arterial bridge was (10.95+/-1.35) approximately (15.30+/-2.82)cm.

CONCLUSION

IEA can bridge the aorta and the coronary artery branches including the left anterior descending branch, the left circumflex branch and the right main coronary artery in free grafting. Its caliber and blood flow rate can match with those of the coronary artery. Before the operation of applying color doppler ultrasound instrument, the safety of IEA in the coronary artery bypass grafting can be evaluated to provide a new safe method in clinical follow-up.

Histologic study of coronary, radial, ulnar, epigastric and internal thoracic arteries: application to coronary artery bypass grafts

The biometry and the histology of coronary, radial, ulnar, epigastric and internal thoracic arteries were studied in order to investigate the cause of their occlusions in coronary bypass grafts and to improve the results of these bypass grafts. These various arteries were removed from 40 anatomical specimens (27 males and 13 females). We found a correlation between the internal calibers of the ulnar and coronary arteries in males. Intimal changes and the presence of atheromatous plaque were observed in coronary, radial and ulnar arteries, but never in the internal thoracic artery. Like coronary arteries and their branches, radial, ulnar and epigastric arteries are muscular arteries and ageing results in thickening of the intima, which becomes fibrotic with migration of myocytes from the media and duplication of the internal elastic lamina. The media becomes fibrous, hypertrophic or atrophic. In contrast, the internal thoracic artery is an elastic artery, like the aorta. Ageing is characterized by loss, over a variable extent, of one or several elastic laminae of the media and more marked intimal thickening. Although anatomically, the caliber of radial, ulnar, and epigastric arteries remains adapted to that of coronary arteries, the long-term patency of radial, ulnar and epigastric arteries used as grafts is related to their histological characteristics.

Utility of the free deep inferior epigastric perforator flap in chest wall reconstruction

Breast cancer chest wall recurrence is often treated with chemotherapy, radical surgery, and radiation. Extensive chest wall resection requires soft-tissue reconstruction with tissue that provides chest wall stability and durability for additional radiation. Local and regional muscle and musculocutaneous flaps are often used for reconstruction. Free flaps, such as the transverse rectus abdominis musculocutaneous flap, are used for large defects, although donor site morbidity can result. The free deep inferior epigastric perforator (DIEP) flap provides coverage for large defects and may have less donor site morbidity. We describe the use of the free DIEP flap to reconstruct large chest wall defects (mean, 501 cm2 defects) after the resection of recurrent breast cancer in two patients. One patient had 2% flap loss. No donor site morbidity occurred. The free DIEP flap is a durable and reliable flap that provided immediate and complete coverage of these large chest wall defects with no donor site morbidity and did not delay the administration of adjuvant therapy.

The use of a deep inferior epigastric perforator flap (DIEP) in a case of severe breast asymmetry secondary to radiation therapy during childhood

Breast radiotherapy during childhood may cause unpredictable outcomes in soft tissue growth and may be responsible for most iatrogenic-related breast hypoplasias. Poor local skin quality and subcutaneous atrophy poses a difficult problem for the use of alloplastic tissues. Clinical use of a deep inferior epigastric perforator flap (DIEP) in oncological breast surgery is a common practice; however few studies have described its application in benign situations and no previous report addressed this subject. The authors indicate the use of the DIEP flap to correct severe hypomastia after previous childhood radiotherapy for hemangioma treatment, followed by unsuccessful alloplastic tissue reconstruction. For selected patients the DIEP flap may constitute a new alternative for complications of radiotherapy treatment due to the possibility of large tissue transfer with minimal donor area morbidity. The quantity of flap tissue necessary to restore the breast mound, the perforator vessel size, and the quality of suitable recipient vessels should be carefully evaluated. However, the need for microsurgical training as well as the extended surgical time are the main limiting factors for the use of this flap.

Limb salvage of infected diabetic foot ulcers with free deep inferior epigastric perforator flaps

Soft-tissue reconstruction of the feet in diabetic patients with angiopathy, sensorial neuropathy, and immunopathy is a complicated problem. Until the mid-1980s, chronic foot ulcers in diabetic patients were treated conservatively, because flap surgery was regarded as too risky. However, in recent years, early debridement and flap coverage have become popular reconstructive methods for diabetic foot wounds. Several flap donor sites are available, depending on the nature of the defect. The deep inferior epigastric artery perforator (DIEP) flap is a relatively new flap that developed as a modification of the transverse rectus abdominis muscle (TRAM) flap. It provides a large amount of skin and subcutaneous tissue, without the donor-site morbidity of the ordinary TRAM flap. Furthermore, using the DIEP flap avoids the loss of major vessels. In this study, we report on the successful use of the DIEP flap in four cases of diabetic foot ulceration.

[Off-pump coronary artery bypass in high-risk patients]

In this study, 110 consecutive patients who had undergone off-pump coronary artery bypass (OPCAB) in the past 2 years were evaluated for early results of OPCAB. Patients were classified as a high-risk group (H group: 68 patients consisting of 46 men and 22 women) and a low-risk group (L group: 42 patients consisting of 31 men and 11 women), respectively, and were evaluated for the early operative results. No differences were noted between the H and L groups in the mean number of bypass grafts (2.9 +/- 0.9 in the H group, 2.9 +/- 0.9 in the L group), the rates of complete revascularization (85% in the H group, 93% in the L group), those of various graft materials bypassed, or those of sequential bypass. In all patients, we were able to undergo coronary revascularization by the aortic no-touch technique using arterial grafts exclusively. In the H group, 1 patient (1.5%) died in hospital, but no patients developed cerebral infarction postoperatively, and the frequency of complications was similar to that in the L group. The results of OPCAB for high-risk patients were good, and it was suggested that OPCAB using in situ arterial grafts was very useful particularly in patients with cerebrovascular diseases.

[Deep inferior epigastric perforator flap for vaginal reconstruction]

OBJECTIVE

To evaluate a new alternative method for the reconstruction of vagina with deep inferior epigastric perforator (DIEP) flap.

METHODS

From January 2004 to May 2005, DIEP flaps were used for vaginal reconstruction in 5 patients (19 to 40 years), including 4 cases of congenital vaginal agenesis and I case of vaginal tumor. Before operation, the perforators were detected by the Doppler and the flaps based on the perforators ranged from 10 cmX 9 cm to 12 cmX 11 cm. DIEP flaps were elevated and then transferred to reconstruct the vagina.

RESULTS

Deep inferior epigastric perforator flaps were used in 5 patients. Only 1 patient developed haematoma in the posterior aspect of the reconstructed vagina, but the flap was viable. The wounds healed secondarily after conservative therapy. All the flaps survived completely. No complication occurred at donor site of abdominal wall.

CONCLUSION

Despite technical difficulties in elevating the deep inferior epigastric perforator flap, the flap is a good choice for vaginal reconstruction.

Complications Associated With Breast Reconstruction Using a Perforator Flap Compared With a Free TRAM Flap

This study evaluated the recipient and donor site complications associated with breast reconstruction using a deep inferior epigastric artery perforator flap (DIEAP) flap compared with a free TRAM flap. The charts of 108 patients who underwent breast reconstruction using these techniques were reviewed. There were 130 flaps. Patients with free TRAM flaps had a significantly longer hospital stay (P=0.003). There were significantly more cases of fat necrosis in the unilateral DIEAP flaps (P=0.001). In patients who were overweight or obese (body mass index >25 kg/m), there were significantly more breast complications (P=0.006). There were more cases of abdominal flap necrosis at the donor site in smokers (P = 0.018) and the diabetic patients (P=0.013). This study suggests that postoperative complications are related to patient comorbidities, and personal factors and should be considered when selecting the most appropriate reconstructive option.

Breast reconstruction with the TRAM flap: Pedicled and free

BACKGROUND

Breast cancer is a ubiquitous disease affecting one in seven women. While breast conservation techniques are available for local control of the disease for many patients, not all patients are good candidates for these techniques. Mastectomy, therefore, remains a common method of breast cancer treatment. Methods of reconstruction include implant reconstruction and autogenous reconstruction. The advantages of autogenous reconstruction include the creation of a soft, ptotic breast mound, which tends to match a native contralateral breast both in and out of bra support. Autogenous reconstructions do not tend to change with time and usually do not require periodic revision as seen in implant reconstructions.

METHODS

The most common method of autogenous reconstruction is the TRAM flap, either pedicled or free. The TRAM flap employs the redundant excess lower abdominal tissue typically removed during a cosmetic abdominoplasty. This tissue is brought to the mastectomy defect as a pedicled flap, passing subcutaneously from the upper abdomen and into the defect site. The pedicled flap is based upon the superior epigastric vessels. A free TRAM is harvested with the overlying muscle and the attached inferior epigastric vessels. This flap is completely separated from the abdomen and brought to the chest defect where it is anastomosed to either the thoracodorsal or internal mammary vessels. The donor defect within the abdominal wall is repaired with an inlay mesh with both the pedicled and free techniques.

RESULTS

Patient selection criteria usually help determine which technique is used. The advantage of the free flap technique is improved blood supply to the skin island. The free flap, therefore, is used in patients at higher risk for partial flap loss with the pedicled technique. Such high-risk patients include smokers, the obese, patients with significant medical comorbidities, and patients with prior abdominal surgery. Patients without these risk factors can be expected to achieve good results with either the pedicled or free flap technique.

CONCLUSION

Autogenous breast reconstruction with the TRAM flap achieves long lasting satisfactory results in most patients with the creation of a soft, naturally ptotic breast mound, which typically matches well a contralateral native breast.

[Breast reconstruction with a combined skin flap of DIEP and TRAM]

OBJECTIVE

To evaluate breast reconstruction with a combined skin flap of the deep inferior epigastric perforator (DIEP) and the transverse rectus abdominis musculocutaneous (TRAM).

METHODS

The DIEP and TRAM united flap was elevated with the vessel pedicle of the deep inferior epigastric perforator on the affected side and the rectus abdominis muscle pedicle on the intact side. The reconstructive breast was shaped after the deep inferior epigastric vessels were anastomosed to the internal mammary vessels or the thoracodorsal vessels ipsilaterally.

RESULTS

We have used the DIEP and TRAM united flaps for breast reconstruction in 17 cases. All of the flaps survived, and the reconstructed breasts were well-shaped with the follow-up of 6-18 months.

CONCLUSIONS

The DIEP and TRAM united flap possesses of advantages such as rich blood supply, abundant tissue volume and easy shaping. It is especially applicable to the cases who have large chest defect and need large volume tissue.

Breast reconstruction using perforator flaps

BACKGROUND

Perforator flaps allow the transfer of the patient's own skin and fat in a reliable manner with minimal donor-site morbidity. The deep inferior epigastric artery (DIEP) and superficial inferior epigastric artery (SIEA) flaps transfer the same tissue from the abdomen to the chest for breast reconstruction as the TRAM flap without sacrificing the rectus muscle or fascia. Gluteal artery perforator (GAP) flaps allow transfer of tissue from the buttock, also with minimal donor-site morbidity.

INDICATIONS

Most women requiring tissue transfer to the chest for breast reconstruction or other reasons are candidates for perforator flaps. Absolute contraindications to perforator flap breast reconstruction include history of previous liposuction of the donor site or active smoking (within 1 month prior to surgery). ANATOMY AND TECHNIQUE: The DIEP flap is supplied by intramuscular perforators from the deep inferior epigastric artery and vein. The SIEA flap is based on the SIEA and vein, which arise from the common femoral artery and saphenous bulb. GAP flaps are based on perforators from either the superior or inferior gluteal artery. During flap harvest, these perforators are meticulously dissected free from the surrounding muscle which is spread in the direction of the muscle fibers and preserved intact. The pedicle is anastomosed to recipient vessels in the chest and the donor site is closed without the use of mesh or other materials.

CONCLUSIONS

Perforator flaps allow the safe and reliable transfer of abdominal tissue for breast reconstruction.

[Immediate breast reconstruction with DIEP flap following modified radical mastectomy]

OBJECTIVE

To review the experience in immediate breast reconstruction with DIEP flap following modified radical mastectomy.

METHODS

From 2003 to 2005, eight patients with breast cancer have undergone modified radical mastectomy and immediate breast reconstruction with deep inferior epigastric perforator flap. Six patients had stage I disease and 2 patients had stage II disease.

RESULTS

The flaps in all the cases survived. Two occurred minor complications. A small part of venous congestion occurred in one flap. One patient had hematoma under the flap. Follow up more than 6 months, no evidence of recurrence and metastasis occurs. Postoperative abdominal wall examination didn't reveal and hernia and bulging. Patient satisfaction with the reconstructed breast was rated high. The reconstructed breast achieved good results in shape, colour and symmetry.

CONCLUSION

The procedure introduced is an ideal method for breast reconstruction after modified radical mastectomy.

Novel Technique for Venous Augmentation in a Free Deep Inferior Epigastric Perforator Flap

Venous congestion in a free deep inferior epigastric perforator flap threatens the viability of the flap and can lead to eventual flap loss. We describe a novel technique for flap salvage by anastomosing the ipsilateral superficial inferior epigastric vein to a venae comitantes of the deep inferior epigastric pedicle. When recognized intraoperatively, venous congestion can be relieved immediately without the need for additional dissection of recipient vessels. This technique can also be used during reexploration for flap congestion. We routinely preserve length on the superficial inferior epigastric vein for potential flap salvage.

Revascularization using arterial conduits for abdominal angina due to isolated and spontaneous dissection of the superior mesenteric artery

Isolated spontaneous dissection of the superior mesenteric artery is rare, and the surgical treatment is not established. We performed successfully total revascularization using arterial conduits (left radial artery and right epigastric artery) and present here the first report to our knowledge of a surgically treated case.