Clinical Relevance of Sensory Nerve Coaptation in DIEP Flap Breast Reconstruction Evaluated Using the BREAST-Q

 

By Bijkerk, Ennie; Beugels, Jop; van Kuijk, Sander M. J.; Lataster, Arno; van der Hulst, René R. W. J.; Tuinder, Stefania M. H.

 

Plastic and Reconstructive Surgery: November 2022 - Volume 150 - Issue 5 - p 959e-969e

 

Background: 

Sensory nerve coaptation in autologous breast reconstruction positively affects sensory recovery in the reconstructed breast. However, patient-reported outcomes are lacking and no conclusions on the clinical relevance of nerve coaptation could be drawn. The aim of this study was to evaluate the clinical relevance of nerve coaptation in deep inferior epigastric perforator (DIEP) flap breast reconstruction.

Methods: 

A prospective cohort study was conducted of patients undergoing innervated or noninnervated DIEP flap breast reconstruction between August of 2016 and August of 2018. Patients completed a BREAST-Q questionnaire at a minimum of 12 months’ follow-up in combination with either a preoperative questionnaire or a questionnaire at 6 months’ follow-up. The physical well-being of the chest domain was the primary outcome and patients answered additional sensation-specific questions. Sensation was measured using Semmes-Weinstein monofilaments.

Results: 

In total, 120 patients were included (65 innervated and 55 noninnervated reconstructions). A clinically relevant difference was found in BREAST-Q scores in favor of patients with innervated reconstructions in general and for delayed reconstructions specifically. Patients with sensate breast reconstruction more often reported better and pleasant sensation.

Conclusions: 

This study demonstrated that nerve coaptation in DIEP flap breast reconstruction, specifically in delayed reconstruction, resulted in clinically relevant improved patient-reported outcomes on the physical well-being of the chest domain of the BREAST-Q and that better sensation was perceived. However, the BREAST-Q does not address sensation adequately, and the introduction and validation of new scales is required to confirm the clinical relevance of nerve coaptation reliably.

 

Closed-Incision Negative-Pressure Therapy Reduces Donor-Site Surgical Wound Dehiscence in DIEP Flap Breast Reconstructions: A Randomized Clinical Trial

 

by Muller-Sloof, Emmy; de Laat, Erik; Kenç, Onur; Kumaş, Ali; Vermeulen, Hester; Hummelink, Stefan; Ulrich, Dietmar J. O. 

 

Plastic and Reconstructive Surgery: October 2022 - Volume 150 - Issue - p 38S-47S

 

Background: 

In breast reconstruction operations, surgical wound dehiscence is a serious complication that generates a significant burden on patients and health care systems. There are indications that postoperative treatment with closed-incision negative-pressure therapy has been associated with reduced wound dehiscence rates. This randomized clinical trial examines the effect of closed-incision negative-pressure application on abdominal donor-site surgical wound dehiscence in low- and high-risk patients undergoing breast reconstruction with a deep inferior epigastric perforator flap.

Methods: 

Eighty eligible women, stratified as low- or high-risk patients, were included and were randomized for treatment with either closed-incision negative-pressure or adhesive strips by drawing sealed, opaque envelopes. All surgeons were kept blinded for allocation. Primary outcomes were surgical wound dehiscence and surgical-site infection at the abdominal donor site on follow-up after 12 weeks. Secondary outcomes were seroma and hematoma formation. Five patients were excluded from the study because of insufficient exposure to the study treatment (n = 4) or major protocol deviation (n = 1).

Results: 

A total of 75 women, low-risk (n = 38) and high-risk (n = 37), received either closed-incision negative-pressure (n = 36) or adhesive strips (n = 39). Patients’ demographics did not differ significantly. Donor-site surgical wound dehiscence occurred in 23 patients; the absolute risk reduction was statistically significant (21.6 percent; 95 percent CI, 1.5 to 41.7 percent). No statistically significant differences were found in surgical-site infection or secondary outcomes.

Conclusion: 

In this randomized clinical trial, postoperative treatment with closed-incision negative-pressure therapy decreased the incidence of surgical wound dehiscence at the abdominal donor site in low- and high-risk deep inferior epigastric perforator flap breast reconstruction patients.

 

 

 

Prospective Longitudinal Patient-Reported Satisfaction and Health-Related Quality of Life following DIEP Flap Breast Reconstruction: Effects of Reconstruction Timing

 

by Ochoa, Oscar; Garza, Ramon III; Pisano, Steven; Chrysopoulo, Minas; Ledoux, Peter; Arishita, Gary; Ketchum, Norma; Michalek, Joel E.; Nastala, Chet 

 

Plastic and Reconstructive Surgery: May 2022 - Volume 149 - Issue 5 - p 848e-857e

 

Background: 

Without reconstruction, mastectomy alone can produce significant detrimental effects on health-related quality of life. The magnitude of quality-of-life benefits following breast reconstruction may be unique based on timing of reconstruction. Facilitated by the BREAST-Q questionnaire, characterization of how reconstruction timing differentially affects patient-reported quality of life is essential for improved evidence-based clinical practice.

Methods: 

Consecutive DIEP flap breast reconstruction patients prospectively completed BREAST-Q questionnaires preoperatively and at two different time intervals postoperatively. The first (postoperative time point A) and second (postoperative time point B) postoperative questionnaires were completed 1 month postoperatively and following breast revision/symmetry procedures, respectively. Postoperative flap and donor-site complications were recorded prospectively. Stratified by timing (immediate versus delayed) of reconstruction, preoperative clinical data, operative morbidity, and BREAST-Q scores were compared at all time points.

Results: 

Between July of 2012 and August of 2016, 73 patients underwent 130 DIEP flap breast reconstructions. Collectively, breast satisfaction, psychosocial well-being, and sexual well-being scores significantly (p < 0.001) increased postoperatively versus baseline. Chest and abdominal physical well-being scores returned to baseline levels by postoperative time point B. Preoperatively, patients undergoing delayed breast reconstruction reported significantly (p < 0.05) lower breast satisfaction, psychosocial well-being, and sexual well-being scores compared to immediate reconstruction patients. Postoperatively, delayed and immediate reconstruction patients reported similar quality-of-life scores. Outcome satisfaction and flap and donor-site morbidity were similar between groups irrespective of timing of reconstruction.

Conclusions: 

In this prospective study, patient-reported outcomes demonstrate significant improvements in breast satisfaction, psychosocial well-being, and sexual well-being among patients following DIEP flap reconstruction. Moreover, preoperative differences in quality-of-life scores among delayed/immediate reconstruction patients were eliminated postoperatively.

 

Nerve Coaptation Improves the Sensory Recovery of the Breast in DIEP Flap Breast Reconstruction

 

by Beugels, Jop; Bijkerk, Ennie; Lataster, Arno; Heuts, Esther M.; van der Hulst, René R. W. J.; Tuinder, Stefania M. H. 

 

Plastic and Reconstructive Surgery: August 2021 - Volume 148 - Issue 2 - p 273-284

 

Background: Restoring the sensation of the reconstructed breast has increasingly become a goal of autologous breast reconstruction. The aim of this study was to analyze the sensory recovery of the breast and donor site of innervated compared to noninnervated deep inferior epigastric perforator (DIEP) flap breast reconstructions, to assess associated factors, and to compare the differences between preoperative and postoperative sensation.

Methods: A prospective cohort study was conducted, including patients who underwent innervated or noninnervated DIEP flap breast reconstruction between August of 2016 and August of 2018. Nerve coaptation was performed to the anterior cutaneous branch of the third intercostal nerve. Preoperative and postoperative sensory testing of the breast and donor site was performed with Semmes-Weinstein monofilaments.

Results: A total of 67 patients with 94 innervated DIEP flaps and 58 patients with 80 noninnervated DIEP flaps were included. Nerve coaptation was significantly associated with lower mean monofilament values for the breast (−0.48; p < 0.001), whereas no significant differences were found for the donor site (−0.16; p = 0.161) of innervated compared to noninnervated DIEP flaps. Factors positively or negatively associated with sensory recovery of the breast and donor site were identified. Preoperative versus postoperative comparison demonstrated significantly superior sensory recovery of the breast in innervated flaps (adjusted difference, −0.48; p = 0.017).

Conclusions: This study demonstrated that nerve coaptation in DIEP flap breast reconstruction significantly improved the sensory recovery of the breast compared to noninnervated flaps. The sensory recovery of the donor site was not compromised in innervated reconstructions. The results support the role of nerve coaptation in autologous breast reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

Quality of life of therapies for hormone receptor positive advanced/metastatic breast cancer: Regulatory aspects and clinical impact in Europe

 

Quality of life of therapies for hormone receptor positive advanced/metastatic breast cancer: Regulatory aspects and clinical impact in Europe

 

by L. Moscetti, I. Sperdutia, A. Frassoldati, A. Musolino, C. Nasso, A. Toss, C. Omarini, M. Dominici, F. Piacentini 

The Breast: Published, July 14, 2021

Purpose

Overall survival in breast cancer patients receiving a delayed deep inferior epigastric perforator (DIEP) flap breast reconstruction is better than in those without delayed breast reconstruction. This study aimed at determining the impact of socioeconomic status (SES) and comorbidity on these observations.

Materials and methods

This matched cohort study included all consecutive women undergoing a delayed DIEP flap reconstruction at Karolinska University Hospital, Sweden, between 1999 and 2013. Controls had not received any delayed breast reconstruction and were relapse-free after a corresponding follow-up interval. Matching was by year of and age at mastectomy, tumour stage and lymph node status. Charlson Comorbidity Index (CCI) and socioeconomic data were obtained from national registers. Associations with breast cancer-specific (BCSS) and overall survival (OS) were investigated by Kaplan-Meier survival estimates and Cox proportional hazard regression analysis.

Results

Women in the DIEP group (N = 254) more often continued education after primary school (88.6% versus 82.6%, P = 0.026), belonged to the high-income group (76.0% versus 63.1%, P < 0.001), were in a partnership (57.1% versus 55.7%, P = 0.024) and healthier (median CCI 1.00 (range 0–13) versus 2.00 (range 0–16), P = 0.021) than the control group (N = 729). After adjustment for tumour and treatment factors, SES and comorbidity, OS remained significantly better for the DIEP group than the control group (HR 2.27, 95% CI 1.44–3.55).

Conclusion

Women with a delayed DIEP flap reconstruction are a subgroup of higher socioeconomic status and better health. Higher survival estimates for the DIEP group persisted after adjusting for those differences, suggesting the presence of further unmeasured covariates.

Neoumbilicus after Selective Excision in Deep Inferior Epigastric Perforator Flap Breast Reconstruction

 Neoumbilicus after Selective Excision in Deep Inferior Epigastric Perforator Flap Breast Reconstruction

 

by Haddock, Nicholas T.; Kelling, Joseph A.; Teotia, Sumeet S. 

 

Plastic and Reconstructive Surgery: November 2020 - Volume 146 - Issue 5 - p 548e-551e

 

Summary:

The umbilicus offers no functional importance to the adult human but remains a key aesthetic landmark of the anterior abdominal wall, and its absence can be a cause for concern in aesthetic and reconstructive patients. Umbilical reconstruction or transposition for abdominoplasty and abdominally based flap operations is frequently complicated by umbilical death, infections, development of wounds needing prolonged wound care, and generally poor aesthetic outcomes. A multitude of techniques have been described to create the “ideal” neoumbilicus, but none has proven to be superior to the technique that comes before it. Our data demonstrate that, in a select set of patients, it may be beneficial to electively remove the umbilicus. Thus, umbilical reconstruction can be performed as an adjunct procedure to the primary operation with a superior aesthetic result and minimal risk for complications. This article describes the authors’ approach to delayed neoumbilical reconstruction in patients undergoing elective umbilical resection.

 

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Efficiency in DIEP Flap Breast Reconstruction: The Real Benefit of Computed Tomographic Angiography Imaging

 Efficiency in DIEP Flap Breast Reconstruction: The Real Benefit of Computed Tomographic Angiography Imaging

 by Haddock, Nicholas T.; Dumestre, Danielle O.; Teotia, Sumeet S. 

Plastic and Reconstructive Surgery: October 2020 - Volume 146 - Issue 4 - p 719-723

Background: In deep inferior epigastric perforator (DIEP) flap breast reconstruction, many surgeons use preoperative imaging for perforator mapping as a method to plan the operation, reduce operative times, and potentially limit morbidity. This study compared operative times for specific portions of DIEP flap harvest with and without preoperative computed tomographic angiography imaging.

Methods: Two patient groups undergoing DIEP flap breast reconstruction were studied prospectively. In the experimental group, the harvesting surgeon was blinded to the preoperative computed tomographic angiography scan; in the control group, the harvesting surgeon assessed the scan preoperatively. Times for initial perforator identification, perforator selection, flap harvest time, and total procedure times were compared. Perforator choice was evaluated. Correlation of perforator choice preoperatively and intraoperatively was also performed.

Results: Times were recorded in 60 DIEP flaps (27 blinded and 33 unblinded). The nonblinded group was more efficient in all categories: time to first perforator identification (28.6 minutes versus 17.8 minutes; p < 0.0001), time to perforator decision-making (23.1 minutes versus 5.6 minutes; p < 0.0001), time to flap harvest (128 minutes versus 80 minutes; p < 0.0001), and total operative time (417 minutes versus 353 minutes; p < 0.001). Perforator location was not different between groups. Blinded intraoperative decisions correlated with preoperative imaging in 74 percent of flaps. More perforators were included in the blinded flaps compared to the nonblinded flaps (2.3 versus 1.4; p < 0.001).

Conclusions: Use of preoperative computed tomographic angiography leads to decreased operative times, specifically with regard to perforator identification and perforator selection. Without preoperative computed tomographic angiography, surgeons included more perforators in the flaps. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

Comparing the Lumbar and SGAP Flaps to the DIEP Flap Using the BREAST-Q

 

Comparing the Lumbar and SGAP Flaps to the DIEP Flap Using the BREAST-Q

 

by Opsomer, Dries; Vyncke, Tom; Ryx, Michelle; Stillaert, Filip; Van Landuyt, Koenraad; Blondeel, Phillip 

 

Plastic and Reconstructive Surgery: September 2020 - Volume 146 - Issue 3 - p 276e-282e

 

Background:

The deep inferior epigastric artery perforator (DIEP) flap is the gold standard in autologous breast reconstruction. When the abdomen is not available, alternative donor sites can be found at the buttock, the lumbar region, or the thighs. These flaps are referred to as second-choice flaps. This study compares the superior gluteal artery perforator (SGAP) flap and the lumbar artery perforator (LAP) flap to the DIEP flap using patient-reported outcomes.

Methods:

A retrospective study was performed reviewing the records of 417 women who underwent a free flap breast reconstruction with either a DIEP, an LAP, or an SGAP flap, between 2006 and 2018. Patients were asked to fill out the BREAST-Q questionnaire, and patient-reported outcomes were analyzed and correlated to the demographic information.

Results:

The response rate was 54.5 percent, with 50 LAP, 153 DIEP, and 25 SGAP flap patients participating. When questioned about their satisfaction with breasts and satisfaction with outcome, all three procedures were rated similarly high. When comparing the physical well-being of the donor site and appearance of the donor site, LAP flap patients reported significantly lower scores than DIEP and SGAP flap patients.

Conclusions:

Patients who undergo LAP or SGAP flap breast reconstruction seem similarly satisfied with the appearance and outcome of their free flap breast reconstruction compared with DIEP flap patients. The donor-site morbidity and its impact on the patient’s well-being in SGAP and LAP flap patients have been underestimated. Despite more donor-site discomfort, the LAP and SGAP flaps are feasible alternatives whenever the DIEP flap is not possible.

Intraoperative Assessment of DIEP Flap Breast Reconstruction Using Indocyanine Green Angiography: Reduction of Fat Necrosis, Resection Volumes, and Postoperative Surveillance

Link to article: Intraoperative Assessment of DIEP Flap Breast Reconstruction Using Indocyanine Green Angiography: Reduction of Fat Necrosis, Resection Volumes, and Postoperative Surveillance

by Hembd, Austin S.; Yan, Jingsheng; Zhu, Hong; Haddock, Nicholas T.; Teotia, Sumeet S.

Plastic and Reconstructive Surgery: July 2020 - Volume 146 - Issue 1 - p 1e-10e

Background:

This study aims to characterize the effect of laser-assisted indocyanine green fluorescence angiography on fat necrosis and flap failure in deep inferior epigastric artery perforator (DIEP) flap breast reconstruction.

Methods:

 A retrospective review was performed on 1000 free flaps for breast reconstruction at a single center from 2010 to 2017. Indocyanine green angiography was used after completion of recipient-site anastomoses to subjectively assess for areas of hypoperfusion. A multivariable logistical analysis was conducted with 24 demographic and surgical factors and their effects on fat necrosis and flap failure.

Results:

Five hundred six DIEP flaps were included in the statistical analyses. Thirteen percent of flaps had fat necrosis. Indocyanine green angiography was used for 200 flaps and was independently associated with a decrease in the odds of fat necrosis (OR, 0.38; p = 0.004). There was no reduction in flap failure rates when using indocyanine green angiography (OR, 1.15; p = 0.85). However, there was a decrease in flap loss with increasing venous coupler diameter (OR, 0.031 per 1-mm increase; p = 0.012). The 84.9-g higher weight of resected tissue before inset without indocyanine green angiography versus the weight of the tissue resected with indocyanine green angiography was statistically significant (p = 0.01). Per single incident of fat necrosis, our cohort underwent an additional 0.69 revision procedures, 1.22 imaging studies, 0.77 biopsies, and 1.7 additional oncologic office visits.

Conclusion:

Intraoperative indocyanine green fluorescence angiography decreases the odds of fat necrosis, saves volume when flap trimming at inset, and can significantly reduce the postoperative surveillance burden in DIEP-based breast reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Outcomes of DIEP Flap and Fluorescent Angiography: A Randomized Controlled Clinical Trial

Outcomes of DIEP Flap and Fluorescent Angiography: A Randomized Controlled Clinical Trial

by Varela, Ramon; Casado-Sanchez, Cesar; Zarbakhsh, Shirin; Diez, Jesus; Hernandez-Godoy, Juan; Landin, Luis

Plastic and Reconstructive Surgery: January 2020 - Volume 145 - Issue 1 - p 1-10

Background: Breast reconstruction with the deep inferior epigastric perforator (DIEP) flap can be associated with complications such as fat necrosis. The authors’ objective was to assess the safety and efficacy of fluorescent angiography with indocyanine green to reduce fat necrosis. Methods: The authors designed a parallel, randomized, controlled clinical trial for unilateral breast reconstruction. The poorly vascularized tissues of the DIEP flap were removed based on a clinical evaluation in group 1 and based on angiographic criteria in group 2. The authors recorded the flap dimensions, perfusion in terms of fluorescence intensity, complications, reoperations, and BREAST-Q questionnaire scores for both groups. Results: The study included a total of 51 patients. The flaps showed no size differences after the tissue was excised. The flaps of group 2 presented higher perfusion rates (p = 0.001). The incidence of fat necrosis was 59.3 percent in group 1 and 8.3 percent in group 2 (p = 0.001). Four cases of partial necrosis were recorded in group 1 (18.2 percent) compared with none in group 2 (0 percent) (p = 0.131). Four patients underwent reoperation in group 1 (14.8 percent) compared with none in group 2 (0 percent) (p = 0.113). The patients in group 2 reported higher scores in all domains of the BREAST-Q. Conclusions: Fluorescent angiography with indocyanine green significantly reduced the incidence of fat necrosis without diminishing the flaps’ dimensions. The perfusion rates were significantly higher and the patients reported significantly greater satisfaction and quality of life. Fluorescent angiography with indocyanine green may be considered a safe and effective tool to enhance the outcomes of breast reconstruction with the DIEP flap. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, I.

Sensory Recovery of the Breast following Innervated and Noninnervated DIEP Flap Breast Reconstruction

Sensory Recovery of the Breast following Innervated and Noninnervated DIEP Flap Breast Reconstruction

by Beugels, Jop; Cornelissen, Anouk J. M.; van Kuijk, Sander M. J.; Lataster, Arno; Heuts, Esther M.; Piatkowski, Andrzej; Spiegel, Aldona J.; van der Hulst, René R. W. J.; Tuinder, Stefania M. H

Plastic and Reconstructive Surgery: August 2019 - Volume 144 - Issue 2 - p 178e-188e

Background: The sensory recovery of the breast remains an undervalued aspect of autologous breast reconstruction. The aim of this study was to evaluate the effect of nerve coaptation on the sensory recovery of the breast following DIEP flap breast reconstruction and to assess the associations of length of follow-up and timing of the reconstruction.

Methods: A prospective comparative study was conducted of all patients who underwent either innervated or noninnervated DIEP flap breast reconstruction and returned for follow-up between September of 2015 and July of 2017. Nerve coaptation was performed to the anterior cutaneous branch of the third intercostal nerve. Semmes-Weinstein monofilaments were used for sensory testing of the native skin and flap skin.

Results: A total of 48 innervated DIEP flaps in 36 patients and 61 noninnervated DIEP flaps in 45 patients were tested at different follow-up time points. Nerve coaptation was significantly associated with lower monofilament values in all areas of the reconstructed breast (adjusted difference, −1.2; p < 0.001), which indicated that sensory recovery of the breast was significantly better in innervated compared with noninnervated DIEP flaps. For every month of follow-up, the mean monofilament value decreased by 0.083 in innervated flaps (p < 0.001) and 0.012 in noninnervated flaps (p < 0.001). Nerve coaptation significantly improved sensation in both immediate and delayed reconstructions. 

Conclusions: This study demonstrated that nerve coaptation in DIEP flap breast reconstruction is associated with a significantly better sensory recovery in all areas of the reconstructed breast compared with noninnervated flaps. The length of follow-up was significantly associated with the sensory recovery.

A New and Innovative Method of Preoperatively Planning and Projecting Vascular Anatomy in DIEP Flap Breast Reconstruction: A Randomized Controlled Trial

A New and Innovative Method of Preoperatively Planning and Projecting Vascular Anatomy in DIEP Flap Breast Reconstruction: A Randomized Controlled Trial

Plastic and Reconstructive Surgery: June 2019 - Volume 143 - Issue 6 - p 1151e–1158e

by Hummelink, Stefan; Hoogeveen, Yvonne L.; Schultze Kool, Leo J.; Ulrich, Dietmar J. O. 

Background: In deep inferior epigastric perforator (DIEP) flap breast reconstructions, a free tissue flap from the abdomen is shaped into a breast and transferred to the thorax. Survival of this free flap relies on minuscule blood vessels, so-called perforators, providing blood supply to this newly molded breast. Preoperative mapping of these randomly distributed blood vessels is essential to avoid complications. The purpose of this study was to investigate whether the preoperative projection of a virtual three-dimensional plan based on computed tomographic angiography onto the abdomen leads to more correctly identified perforator locations and less operative time spent on dissecting the free flap compared to the commonly used Doppler ultrasound planning method.

Methods: The authors conducted a randomized, open, single-center, superiority trial in patients undergoing DIEP flap breast reconstruction with 1-week follow-up. Randomized participants were 60 adults (projection method, n = 33; Doppler method, n = 27) undergoing DIEP flap breast reconstruction without lymph node transfer.

Results: Sixty patients provided 69 DIEP flaps for analysis. The projection method is capable preoperatively of displaying significantly more perforators compared to the Doppler method (61.7 ± 7.3 percent versus 41.2 ± 8.2 percent, respectively; p = 0.020)). During the procedure, flap harvest time is decreased by 19 minutes (136 ± 7 minutes versus 155 ± 7 minutes; p = 0.012). Complications were comparable across both groups.

Conclusion: Not only can more perforators be identified intraoperatively using the projection method compared with Doppler ultrasound, there is also a significant time reduction in harvesting the DIEP flap. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

Myth-Busting the DIEP Flap and an Introduction to the Abdominal Perforator Exchange (APEX) Breast Reconstruction Technique: A Single-Surgeon Retrospective Review

Myth-Busting the DIEP Flap and an Introduction to the Abdominal Perforator Exchange (APEX) Breast Reconstruction Technique: A Single-Surgeon Retrospective Review

by DellaCroce, Frank J.; DellaCroce, Hannah C.; Blum, Craig A.; Sullivan, Scott K.; Trahan, Christopher G.; Wise, M. Whitten; Brates, Irena G.

Plastic and Reconstructive Surgery:  April 2019 - Volume 143 - Issue 4 - p 992-1008

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.

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.

Optimizing DIEP Flap Insetting for Immediate Unilateral Breast Reconstruction: A Prospective Cohort Study of Patient-Reported Aesthetic Outcomes

Optimizing DIEP Flap Insetting for Immediate Unilateral Breast Reconstruction: A Prospective Cohort Study of Patient-Reported Aesthetic Outcomes

 by Razzano, Sergio; Marongiu, Francesco; Wade, Ryckie; Figus, Andrea  

Plastic and Reconstructive Surgery: February 2019 - Volume 143 - Issue 2 - p 261e–270e

Background: To improve the aesthetic outcome of deep inferior epigastric perforator (DIEP) flap breast reconstruction, flaps should be tailored to the patient’s characteristics. A single method of DIEP flap insetting will not suffice for all women seeking breast reconstruction. The authors share the outcomes of a prospective longitudinal study on DIEP flap insetting and present an algorithm for reconstruction.

Methods: Over 4 years, 70 consecutive immediate unilateral DIEP flap breast reconstructions were prospectively evaluated. DIEP insetting was based on the characteristics of the donor site and contralateral breast, according to the authors’ algorithm. Baseline and outcome data were collected. Aesthetic outcomes were evaluated by a panel of three independent assessors, and patient-reported outcomes were quantified using the BREAST-Q at 1 year after reconstruction.

Results: Seventy women underwent reconstruction. There were no total or partial flap failures, four cases of fat necrosis, and 14 revision operations. Women reported a mean overall BREAST-Q score of 82 of 100, representing excellent satisfaction but poor satisfaction with sexual well-being. BREAST-Q scores were not associated with age or body mass index. Fat necrosis reduced satisfaction with the chest (absolute mean reduction, 13; 95 percent CI, 8 to 18; p = 0.002). Independent assessors scored the outcomes favorably, but there was no agreement between surgeons, nurses, and lay assessors. Conclusions: The authors’ algorithm can support surgeons in selecting individually tailored DIEP flap insetting to achieve excellent aesthetic outcomes. Further research is needed as to the relevance of scores from BREAST-Q in relation to interventions. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Optimizing Perforator Selection: A Multivariable Analysis of Predictors for Fat Necrosis and Abdominal Morbidity in DIEP Flap Breast Reconstruction

Optimizing Perforator Selection: A Multivariable Analysis of Predictors for Fat Necrosis and Abdominal Morbidity in DIEP Flap Breast Reconstruction

by Hembd, Austin; Teotia, Sumeet S.; Zhu, Hong; Haddock, Nicholas T.  

Plastic and Reconstructive Surgery: September 2018 - Volume 142 - Issue 3 - p 583–592

Background: This study aims to elucidate the important predicting factors for fat necrosis and abdominal morbidity in the patient undergoing deep inferior epigastric artery perforator flap reconstruction.

 Methods: The authors conducted a retrospective review of 866 free-flap breast reconstructions performed at one institution from 2010 to 2016. Twenty-eight potential predictors were included in multivariable analyses to control for possible confounding interactions.

Results: Four hundred nine total deep inferior epigastric artery perforator flaps were included in the statistical analysis. Of these, 14.4 percent had flap fat necrosis, 21.3 percent had an abdominal wound or complication, and 6 percent had an abdominal bulge or hernia. Analysis showed an increase in the odds of fat necrosis with increasing flap weight (OR, 1.002 per 1-g increase; p = 0.0002). A decrease in the odds of fat necrosis was seen with lateral row (OR, 0.29; p = 0.001) and both medial and lateral row perforator flaps (OR, 0.21; p = 0.001), if indocyanine green angiography was used (OR, 0.46; p = 0.04), and with increasing total flow rate of the flap (OR, 0.62 per 1-mm/second increase; p = 0.05). Increased odds of abdominal bulge or hernia were seen with lateral row or both medial and lateral row perforators (OR, 3.21; p = 0.05) versus medial row perforator-based flaps, and with patients who had an abdominal wound postoperatively (OR, 2.59; p = 0.05).

Conclusions: The authors’ results suggest that using larger caliber perforators and perforators from the lateral row alone, or in addition to medial row perforators, can decrease fat necrosis more than simply harvesting more perforators alone. However, lateral and both medial and lateral row perforator flaps come at the cost of increasing abdominal bulge rates. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Comparison of Immediate versus Delayed DIEP Flap Reconstruction in Women Who Require Postmastectomy Radiotherapy

Comparison of Immediate versus Delayed DIEP Flap Reconstruction in Women Who Require Postmastectomy Radiotherapy

By O’Connell, Rachel L.; Di Micco, Rosa; Khabra, Komel; Kirby, Anna M.; Harris, Paul A.; James, Stuart E.; Power, Kieran; Ramsey, Kelvin W. D.; Rusby, Jennifer E.  

Plastic and Reconstructive Surgery: September 2018 - Volume 142 - Issue 3 - p 594–605

Background: The authors investigated aesthetic outcome and patient satisfaction in women who have undergone deep inferior epigastric artery perforator (DIEP) flap reconstruction in the setting of postmastectomy radiotherapy. Patients who underwent DIEP flap reconstruction without postmastectomy radiotherapy were the control group.

Methods: Participants who had undergone DIEP flap reconstruction between September 1, 2009, and September 1, 2014, were recruited, answered the BREAST-Q, and underwent three-dimensional surface-imaging. A panel assessed the aesthetic outcome by reviewing these images. Results: One hundred sixty-seven women participated. Eighty women (48 percent) underwent immediate DIEP flap reconstruction and no postmastectomy radiotherapy; 28 (17 percent) underwent immediate DIEP flap reconstruction with postmastectomy radiotherapy; 38 (23 percent) underwent simple mastectomy, postmastectomy radiotherapy, and DIEP flap reconstruction; and 21 (13 percent) underwent mastectomy with temporizing implant, postmastectomy radiotherapy, and DIEP flap reconstruction. Median satisfaction scores were significantly different among the groups (p < 0.05). Post hoc comparison demonstrated that women who had an immediate DIEP flap reconstruction were significantly less satisfied if they had postmastectomy radiotherapy. In women requiring radiotherapy, those undergoing delayed reconstruction after a simple mastectomy were most satisfied, but there was no significant difference between the immediate DIEP flap and temporizing implant groups. Median panel scores differed among groups, being significantly higher if the immediate reconstruction was not subjected to radiotherapy. There was no significant difference in panel assessment among the three groups of women who had received radiotherapy.

Conclusions: Patients who avoid having their immediate DIEP flap reconstruction irradiated are more satisfied and have better aesthetic outcome than those who undergo postmastectomy radiotherapy. In women requiring radiotherapy and who wish to have an immediate or “delayed-immediate” reconstruction, there were no significant differences in panel or patient satisfaction. Therefore, immediate DIEP flap reconstruction or mastectomy with temporizing implant then DIEP flap surgery are acceptable treatment pathways in the context of post-mastectomy radiotherapy.

Venous Superdrainage in DIEP Flap Breast Reconstruction: The Impact of Superficial Inferior Epigastric Vein Dissection on Abdominal Seroma Formation

Venous Superdrainage in DIEP Flap Breast Reconstruction: The Impact of Superficial Inferior Epigastric Vein Dissection on Abdominal Seroma Formation

Nedomansky, J et al
Plastic and Reconstructive Surgery: February 2018 - Volume 141 - Issue 2 - p 206e–212e

Background: Abdominal seroma formation after deep inferior epigastric perforator (DIEP) flap breast reconstruction is a common donor-site complication. Additional dissection of one or both of the superficial inferior epigastric veins (SIEVs) in DIEP flap breast reconstruction allows an additional anastomosis for venous superdrainage if venous congestion occurs. However, generally, SIEV dissection involves greater invasiveness into the inguinal region, which can traumatize lymphatic tissue and lead to lymph accumulation. The aim of this study was to evaluate the impact of SIEV dissection on the incidence of postoperative abdominal seroma. 
Methods: A series of 100 consecutive cases performed by the Department of Plastic and Reconstructive Surgery at the Medical University of Vienna from 2001 to 2016 was analyzed. Patients were divided into three groups: unilateral, bilateral, and no SIEV dissection. Abdominal seroma rates, length of hospital stay, abdominal drainage duration, and drainage fluid volumes were compared retrospectively. 
Results: Seromas were observed in 11.5 percent of patients without SIEV dissection, 17.2 percent of patients with unilateral SIEV dissection (p = 0.45 versus no SIEV), and 40 percent of patients with bilateral SIEV dissection (p = 0.02 versus no SIEV). The SIEV was anastomosed to salvage a congested DIEP flap twice. All seromas that developed could be treated with, on average, two fine-needle aspirations without any complications. 
Conclusions: Bilateral, but not unilateral, SIEV dissection increased abdominal seroma rates significantly. Venous congestion was observed rarely, but when it did occur, it endangered flap viability. Because an additional anastomosis of the SIEV can salvage a flap, unilateral SIEV dissection should be considered when raising a DIEP flap.

Evidence-Based Clinical Practice Guideline: Autologous Breast Reconstruction with DIEP or Pedicled TRAM Abdominal Flaps

Evidence-Based Clinical Practice Guideline: Autologous Breast Reconstruction with DIEP or Pedicled TRAM Abdominal Flaps

Lee, B et al
Plastic and Reconstructive Surgery: November 2017 - Volume 140 - Issue 5 - p 651e–664e

The American Society of Plastic Surgeons commissioned a multistakeholder Work Group to develop recommendations for autologous breast reconstruction with abdominal flaps. A systematic literature review was performed and a stringent appraisal process was used to rate the quality of relevant scientific research. The Work Group assigned to draft this guideline was unable to find evidence of superiority of one technique over the other (deep inferior epigastric perforator versus pedicled transverse rectus abdominis musculocutaneous flap) in autologous tissue reconstruction of the breast after mastectomy. Presently, based on the evidence reported here, the Work Group recommends that surgeons contemplating breast reconstruction on their next patient consider the following: the patient’s preferences and risk factors, the setting in which the surgeon works (academic versus community practice), resources available, the evidence shown in this guideline, and, equally important, the surgeon’s technical expertise. Although theoretical superiority of one technique may exist, this remains to be reported in the literature, and future methodologically robust studies are needed.

The short and ultrashort-pedicle deep inferior epigastic artery perforator flap in breast reconstruction

The short and ultrashort-pedicle deep inferior epigastic artery perforator flap in breast reconstruction. Plastic & reconstructive surgery, Feb 2012, Vol. 129(2), p. 331-340.

Colohan, S., et al.

http://journals.lww.com/plasreconsurg/Abstract/2012/02000/The_Short__and_Ultrashort_Pedicle_Deep_Inferior.7.aspx

Breast reconstruction using the deep inferior epigastric perforator (DIEP) flap is becoming more common and can help reduce donor site morbidity. The authors proposed that dissection of the deep inferior epigastric artery (DIEA) and vein (DIEV) to their external iliac source may not be required for safe flap transfer.

Plastic and Reconstructive Surgery Vol 127 Iss 2 February 2011

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Introducing the Septocutaneous Gluteal Artery Perforator Flap: A Simplified Approach to Microsurgical Breast Reconstruction.
pg. 489-495
Tuinder, Stefania M.D et al.

Does Previous Chest Wall Irradiation Increase Vascular Complications in Free Autologous Breast Reconstruction?
pg. 496-504
Fosnot, Joshua M.D et al.

A Combined Anatomical and Clinical Study for Quantitative Analysis of the Microcirculation in the Classic Perfusion Zones of the Deep Inferior Epigastric Artery Perforator Flap
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Rahmanian-Schwarz, Afshin M.D et al.

An 8-Year Experience of Direct-to-Implant Immediate Breast Reconstruction Using Human Acellular Dermal Matrix (AlloDerm).
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Occult Carcinoma in 866 Reduction Mammaplasties: Preserving the Choice of Lumpectomy.
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Temporary Banking of the Nipple-Areola Complex in 97 Skin-Sparing Mastectomies.
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