by DellaCroce,
Frank J.; DellaCroce, Hannah C.; Blum, Craig A.; Sullivan, Scott K.; Trahan,
Christopher G.; Wise, M. Whitten; Brates, Irena G.
Background: Anatomical variations in perforator arrangement may impair the
surgeon’s ability to effectively avoid rectus muscle transection without
compromising flap perfusion in the deep inferior epigastric artery perforator
(DIEP) flap.
Methods: A single surgeon’s experience was reviewed with consecutive patients
undergoing bilateral abdominal perforator flap breast reconstruction over 6
years, incorporating flap standardization, pedicle disassembly, and algorithmic
vascular rerouting when necessary. Unilateral reconstructions were excluded to
allow for uniform comparison of operative times and donor-site outcomes. Three
hundred sixty-four flaps in 182 patients were analyzed. Operative details and
conversion rates from DIEP to abdominal perforator exchange (“APEX”) arms of
the algorithm were collected. Patients with standardized DIEP flaps served as
the controlling comparison group, and outcomes were compared to those who
underwent abdominal perforator exchange conversion.
Results: The abdominal perforator exchange conversion rate from planned DIEP flap surgery was 41.5 percent. Mean additional operative time to use abdominal perforator exchange pedicle disassembly was 34 minutes per flap. Early postsurgical complications were of low incidence and similar among the groups. One abdominal perforator exchange flap failed, and there were no DIEP flap failures. One abdominal bulge occurred in the DIEP flap group. There were no abdominal hernias in either group. Fat necrosis rates (abdominal perforator exchange flap, 2.4 percent; DIEP flap, 3.4 percent) were significantly lower than that historically reported for both transverse rectus abdominis musculocutaneous and DIEP flaps.
Results: The abdominal perforator exchange conversion rate from planned DIEP flap surgery was 41.5 percent. Mean additional operative time to use abdominal perforator exchange pedicle disassembly was 34 minutes per flap. Early postsurgical complications were of low incidence and similar among the groups. One abdominal perforator exchange flap failed, and there were no DIEP flap failures. One abdominal bulge occurred in the DIEP flap group. There were no abdominal hernias in either group. Fat necrosis rates (abdominal perforator exchange flap, 2.4 percent; DIEP flap, 3.4 percent) were significantly lower than that historically reported for both transverse rectus abdominis musculocutaneous and DIEP flaps.
Conclusions: This study revealed no added risk when using
pedicle disassembly to spare muscle/nerve structure during abdominal perforator
flap harvest. Abdominal bulge/hernia was nearly completely eliminated. Fat
necrosis rates were extremely low, suggesting benefit to pedicle disassembly
and vascular routing exchange when required. CLINICAL QUESTION/LEVEL OF
EVIDENCE: Therapeutic, III.
