Contour abnormalities of the abdomen after breast reconstruction with abdominal flaps: the role of muscle preservation

Abdominal wall complications: An unknown aspect of morbidity in phalloplasty. A comprehensive analysis and clinical implications

BACKGROUND

Phalloplasty is a complex reconstructive procedure with complications broadly categorized as urinary, vascular, or donor-site related. This study investigates abdominal wall complications, such as bulging and lateral hernias, associated with the use of the inferior epigastric artery as the recipient vessel in microsurgical phalloplasty-a rare and underreported complication.

METHODS

A retrospective review was conducted on 37 patients who underwent microsurgical phalloplasty at a university hospital from January 2016 to February 2020. The most commonly employed technique was forearm flap phalloplasty, followed by the MSLD flap technique. The inferior epigastric artery was accessed via a 7cm oblique incision. Data collected included demographic details, BMI, smoking status, surgical technique, recipient vessel used, and postoperative complications. Follow-up evaluations were performed at 15 days, 3 months, 6 months, and 1 year postoperatively.

RESULTS

Of the 37 patients, the mean age was 33 years, with 84% undergoing phalloplasty for gender affirmation. Abdominal wall complications occurred in 11% of patients (n=4). Three patients developed parietal complications (hernia or bulging), all requiring surgical revision. All three were smokers, one had a BMI>28, and none had prior abdominal surgeries. Contributing factors included musculoaponeurotic disruption, relative denervation from vessel exposure, and smoking-related wound healing impairment.

CONCLUSIONS

The use of the inferior epigastric artery in microsurgical phalloplasty may increase the risk of abdominal wall complications, particularly in smokers and patients with elevated BMI. Optimizing preoperative risk factors, including smoking cessation and careful vessel selection, is essential for reducing these complications. To reduce the occurrence of these complications, the choice of the recipient vessel should be considered alongside the surgical technique during operative planning. Further studies should explore technical refinements to minimize abdominal wall morbidity.

The enhanced-view totally extraperitoneal repair of abdominal bulge after DIEP flap breast reconstruction for breast cancer: a case report

BACKGROUND

The deep inferior epigastric perforator (DIEP) flap for autologous breast reconstruction is associated with higher patient satisfaction and fewer abdominal morbidities at the donor site than the transverse rectus abdominis myocutaneous flap. However, abdominal bulging occurs at a certain frequency, and there is no established treatment. Here, we present a case of laparoscopic hernia repair using the enhanced-view totally extraperitoneal (eTEP) method in a patient with a lower abdominal bulge after DIEP flap reconstruction.

CASE PRESENTATION

A 53-year-old woman underwent left nipple-sparing mastectomy, left axillary lymph node dissection, and breast reconstruction with a DIEP flap for left breast cancer 3 years previously. We performed an eTEP method for an abdominal bulge. The absence of a hernia sac facilitated dissection of the retrorectal space, and a left-sided transversus abdominis release was performed, followed by mesh placement. No postoperative abdominal bulging was observed.

CONCLUSIONS

Using the eTEP method for repairing an abdominal bulge after DIEP flap reconstruction is advantageous because it facilitates a relatively straightforward dissection of a wide area of the retrorectal space without a hernia sac.

Long-term Donor Site-related Quality of Life after Deep Inferior Epigastric Perforator Flap Breast Reconstruction

Background

Current knowledge about patients' perceptions of the donor site following abdominal-based breast reconstruction and its effect on health-related quality of life (HRQoL) several years after breast reconstruction is limited. This study aimed to assess the long-term effects of deep inferior epigastric perforator (DIEP) flap breast reconstruction on HRQoL, specifically focusing on the abdomen and donor site aspects.

Methods

This retrospective cohort study compared 66 women who underwent DIEP breast reconstruction between 2000 and 2007 with a matched control cohort of 114 women who underwent therapeutic mastectomies without reconstruction in the year 2005. The DIEP cohort of patients completed the BREAST-Q Reconstruction module during an outpatient visit in 2015-2016. The control cohort completed the same questionnaire online in 2016.

Results

The follow-up time was at least 8 years (mean 11.4 ± 1.6 years) postreconstruction for the DIEP cohort and 10 years postmastectomy (mean 11.0 ± 0.3 years) for the control cohort. In the DIEP cohort, 93% reported no donor site pain, 89% had no difficulty sitting up, and 91% had no activity limitations 2 weeks before completing the survey. Patients undergoing DIEP were more satisfied with their abdominal appearance than the control group (adjusted OR, 5.7; 95% confidence interval 1.8-17.6).

Conclusions

A decade postoperatively, DIEP breast reconstruction yields high abdominal donor site satisfaction, with comparable abdominal physical well-being to nonreconstructed women.

Patient-Reported Abdominal Morbidity Following Abdomen-Based Breast Reconstruction

BACKGROUND

 Abdominal wall morbidity occurs with increased frequency following flap harvest in the obese abdomen. Its impact on patient-reported outcomes (PROs) in breast reconstruction has been poorly characterized.

METHODS

 A retrospective review of obese patients undergoing abdominal-based free autologous breast reconstruction was conducted over 15 years. Patient operative characteristics were recorded and outcomes were analyzed. PROs were assessed using the BREAST-Q abdominal survey.

RESULTS

 In total, 75 women (108 flaps) with the mean body mass index (BMI) of 33.2 were included. Flaps included deep inferior epigastric artery perforator (24%), muscle-sparing (43%), and free transverse rectus abdominis myocutaneous flaps (f-TRAM; 33%). World Health Organization (WHO) obesity class, BMI, and flap type did not affect flap failure (1%) or complication rates. Hernia developed in 7%; all necessitated repair. Eight percent developed abdominal bulge; one was repaired. Hernia formation was associated with increased patient age (p < 0.05). Bulge formation occurred more often in f-TRAM donor sites (p = 0.005). BMI, WHO class, flap type, and mesh use were not related to hernia or bulge occurrence in either univariate or multivariate analysis. The survey response rate was 63%. Abdominal Physical Well-Being (proxy for abdominal wall function) and Satisfaction with Abdomen (patient-perceived cosmesis) were similar across flap types, age, and WHO classification groups. Patients with postoperative bulge reported higher abdominal physical well-being scores, regardless of flap type (p < 0.01). Bulge was correlated with lower satisfaction (p < 0.05).

CONCLUSION

 The incidence of abdominal wall morbidity following abdominal free-tissue transfer for breast reconstruction was acceptably low in our population of obese patients. Hernia was a clinically significant complication, warranting surgical repair. Bulge was primarily a cosmetic concern and did not detract from patient-reported abdominal wall function. Age may represent an independent risk factor for hernia formation in this population.

Trunk Muscle Function and Core Stability in Women Who Had Muscle-Sparing Pedicled Transverse Rectus Abdominis Myocutaneous Flap Breast Reconstruction

OBJECTIVE

The long-term effects of the unilateral muscle-sparing pedicled transverse rectus abdominis myocutaneous (TRAMmsp) flap procedure on trunk muscle performances and core stability were investigated in women with breast cancer.

METHODS

Forty women (mean age = 42.6 years) who had received breast reconstruction with the unilateral TRAMmsp flap procedure no less than 6 months earlier (mean = 10.3 [standard deviation, SD = 4.9] months) (TRAM group) participated, and 30 women who were healthy and matched for age (mean age = 41.2 years) served as controls (control group). Their abdominal and back muscle strength was assessed using the curl-up and prone extension tests, respectively, and their static abdominal muscle endurance and back extensor endurance were assessed using the sit-up endurance test in the crook-lying position and the Biering-Sørensen test, respectively. Core stability strength was assessed using a 4-level limb-lowering test (abdominal muscle test), and core stability endurance was assessed while lying supine with both flexed legs 1 inch off the mat while keeping the pelvis in a neutral position with a pressure biofeedback unit.

RESULTS

Compared with the control group, trunk muscles of the TRAM group were weaker, showing less endurance, as were their core stability strength and endurance. Static trunk muscle endurances and trunk flexion strength were associated with core stability in both groups.

CONCLUSIONS

Women exhibit trunk flexor and extensor weakness along with poor endurance and impaired core stability even after an average of 10 months from receiving the TRAMmsp flap procedure. Immobilization after surgery, with possible systemic inflammatory effects from surgery and chemotherapy, might have further contributed to the generalized weakness subsequent to the partial harvesting of the rectus abdominis.

IMPACT

Women after breast reconstruction with the TRAMmsp flap procedure show long-lasting deficits of strength and endurance in abdominal muscles, back extensors, and core stability. Proactive measures including early detection and evaluation of impairments as well as timely intervention targeting these clients are important to minimize the dysfunction and support their return to community participation.

Abdominal donor-site complications following autologous breast reconstruction: A multi-institutional multisurgeon study

BACKGROUND

The deep inferior epigastric perforator (DIEP) free flap is the gold standard procedure for autologous breast reconstruction. Although breast-related complications have been well described, donor-site complications and contributing patient risk factors are poorly understood.

METHODS

We examined a multi-institutional, prospectively maintained database of patients undergoing DIEP free flap breast reconstruction between 2015 and 2020. We evaluated patient demographics, operative details, and abdominal donor-site complications. Logistic regression modeling was used to predict donor-site outcomes based on patient characteristics.

RESULTS

A total of 661 patients were identified who underwent DIEP free flap breast reconstruction across multiple institutions. Using logistic regression modeling, we found that body mass index (BMI) was an independent risk factor for umbilical complications (odds ratio [OR] 1.11, confidence interval [CI] 1.04-1.18, p = 0.001), seroma (OR 1.07, CI 1.01-1.13, p = 0.003), wound dehiscence (OR 1.10, CI 1.06-1.15, p = 0.001), and surgical site infection (OR 1.10, CI 1.05-1.15, p = 0.001) following DIEP free flap breast reconstruction. Further, immediate reconstruction decreases the risk of abdominal bulge formation (OR 0.22, CI 0.108-0.429, p = 0.001). Perforator selection was not associated with abdominal morbidity in our study population.

CONCLUSIONS

Higher BMI is associated with increased abdominal donor-site complications following DIEP free flap breast reconstruction. Efforts to lower preoperative BMI may help decrease donor-site complications.

Utility of the intraflap perfusion procedure for abdominal free flap in unilateral breast reconstruction

BACKGROUND

Heparin prophylaxis for venous thromboembolism can be used in microsurgery. If vein anastomosis is performed before the artery, heparin irrigation into the artery can be performed locally without systematic effect. This study aimed to introduce this "intraflap perfusion procedure" in autologous breast reconstruction.

METHODS

Among the 220 patients with unilateral breast cancer who had received the free abdominal flap, we retrospectively compared those that had undergone the intraflap perfusion procedure (n = 108) and those who did not (n = 112). A 10 mL injection of heparinized physiological saline solution (100 units/mL) was administered into the deep inferior epigastric artery. Intraflap perfusion was performed before, during, and after vein anastomosis, without the vessel clip of the vein. Artery anastomosis was performed without the use of a vein clamp. Further, vein anastomosis was performed tightly to prevent leakage from the vein anastomosis site during artery anastomosis.

RESULTS

The rates of superficial inferior epigastric vein (SIEV) superdrainage (18.5% vs. 42.0%, P < 0.001), and intraoperative flap congestion (0.9% vs. 8.0%, P = 0.01) were significantly lower in patients undergoing this procedure. There were no significant differences regarding other factors (age, BMI, laterality, comorbidities, and other operative details).

CONCLUSIONS

Intraflap perfusion prevented long-term stasis at the venous anastomosis site and capillary level. It could reduce flap congestion. SIEV superdrainage was performed to manage flap congestion, particularly in patients who did not undergo this procedure. Consequently, it can be inferred that this procedure reduces the rate of superdrainage.

Correlation between abdominal visceral volume measured by a simple procedure and bulging at the abdominal free flap donor site for breast reconstruction

BACKGROUND

Breast reconstructions using autologous abdominal tissue result in breasts with a natural shape and consistency. One of the major complications is abdominal bulging. Because of the increased abdominal wall tension, high visceral volume (not visceral fat alone) may increase the occurrence rate of abdominal bulging. A simple procedure involving CT imaging was used to assess this relationship in patients undergoing an abdominal free flap for unilateral breast reconstruction.

METHODS

A total of 278 patients were enrolled in this study. The patients' demographics, the thicknesses of visceral volume were compared (Bulging (+) vs. Bulging (-)). Visceral volume was investigated based on the horizontal thickness, which was measured at the thickest part at the level of the umbilical fossa between both sides under the transverse abdominis muscles.

RESULTS

Bulging (+) consisted of 39 patients (14.0%), whereas Bulging (-) included 239 patients. Patients with Bulging (+) were significantly older, had higher gestational history rate, and had thin rectus abdominis muscle. In terms of visceral volume, the Bulging (+) group had significantly higher horizontal thicknesses (median 233 mm vs. 219 mm, P < 0.001). No significant differences were observed with respect to other factors (age, BMI, history of laparotomy, and operative details). The multivariate logistic regression analysis revealed that the thickness of the rectus abdominis muscle, horizontal visceral volume, and gestational history were independently significant predictors.

CONCLUSIONS

Not only the patients with thin rectus abdominis muscle but also patients with a thick horizontal visceral volume may have a higher risk of abdominal bulging.

A Bayesian Network Meta-Analysis of Complications Related to Breast Reconstruction Using Different Skin Flaps After Breast Cancer Surgery

BACKGROUND AND OBJECTIVES

As the incidence of breast cancer rises, the number of mastectomy surgeries surges, so does the importance of postoperative breast reconstruction. The implementation of autologous flap restoration methods is becoming prevalent, although which is the best flap remains controversial. As a result, we performed a Bayesian network meta-analysis to compare the eight most common flap in the reconstruction processor of breast cancer surgery. Our findings may help surgeons decide which skin flaps to use for breast reconstruction.

METHODS

We searched PubMed, Medline, Embase, and the Cochrane library for relevant literature. For our Bayesian network meta-analysis, we scrutinized 37 papers and evaluated the postoperative complications of eight commonly used breast reconstruction procedures. We also registered this study on PROSPERO, with the number CRD42021251989.

RESULTS

A total of 21,184 patients were included in this Bayesian network meta-analysis from 37 different studies. The results demonstrate that TRAM flaps are more prone to complications such as hernias in the abdominal wall and blood flow problems. Hematoma and seroma are more likely to follow LDP flaps. Combining LDP flaps with a prosthetic or autologous adipose tissue does not enhance the risk of postoperative problems appreciably. Fat liquefaction are relatively common in DIEP.

CONCLUSIONS

After breast reconstruction, several skin flaps can be employed as clinical choices. TRAM flaps are not recommended for patients with a weak abdominal wall structure, although LDP flaps or SIEA flaps can be considered instead. We do not advocate LDP flaps for patients who have had breast surgery because of the higher risk of hematoma or seroma, but DIEP flaps or LAP flaps can be utilized instead. We do not propose DIEP flaps for individuals who are at a higher risk of postoperative fat liquefaction, but LDP flaps or SIEA flaps can be used instead. However, this Bayesian network meta-analysis has limitations, and further randomized controlled trials are needed to confirm its findings.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

The correlation of flap blood glucose with fat necrosis of free abdominal flap for unilateral breast reconstruction

BACKGROUND

Flap blood glucose (FBG) measurement is proposed as a monitoring technique. A cause of long-lasting fever could be derived from fat necrosis. If the findings of low FBG correlated with fat necrosis, it could predict the poor cosmetic result and a source of fever. However, this correlation remained unsolved. The purpose of this study was to clarify this correlation in breast reconstruction.

METHODS

In the 180 unilateral breast cancer patients (mean age = 49.8 years) performed free abdominal flap, we retrospectively compared the group where fat necrosis occurred with the group where it did not occur (45 patients with fat necrosis vs. 135 patients without). We compared the average of FBG in each postoperative day.

RESULTS

The average FBG was significantly lower in patients with fat necrosis in the second postoperative day (115.3 ± 27.3 vs. 126.3 ± 13.7 mg/dl, p = .026) and the third postoperative day (111.1 ± 22.1 vs. 118.8 ± 13.8 mg/dl, p = .036). Mean BMI and inserted total flap weight were significantly higher in patients with the fat necrosis group (24.8 vs. 22.9 kg/m² , p = .005) (617 vs. 478 g, p = .006). The multivariate analysis revealed early FBG (OR = 0.96, p = .0002) and laterality (right side) (OR = 0.46, p = .043) were independently significant predictors. There were no significant between-group differences regarding other factors (age, systemic blood glucose, comorbidities and operative details).

CONCLUSIONS

The possibility of fat necrosis was high for patients with low FBG in the early postoperative day.

Morbidity of the Donor Site and Complication Rates of Breast Reconstruction with Autologous Abdominal Flaps: A Systematic Review and Meta-Analysis

Background. Numerous studies have evaluated the use of autologous abdominal tissue for breast reconstruction; nevertheless, complications and donor site morbidity rates vary significantly. The study aims to compare the literature regarding morbidity of the donor site and complication rates of breast reconstruction with autologous abdominal flaps. Methods. The databases of MEDLINE, EBSCO, Scopus, Wiley Library, and Web of Sciences were searched for studies that compared different flaps in terms of complications and donor site morbidity. The procedures studied included pedicled transverse rectus abdominis myocutaneous flap (pTRAM), free TRAM (fTRAM), deep inferior epigastric perforator (DIEP), and superficial inferior epigastric artery perforator (SIEA) flaps. A total of 34 studies were included. Of these, 28 were retrospective studies and 9 were prospective cohort studies. Results. When compared to DIEP, fTRAM flaps were found to have a decreased incidence of flap fat necrosis, hematoma, and total thrombotic events, yet a higher risk of donor site hernia/bulging. pTRAM flaps were also associated with an increased risk of hernia/bulging at the donor site, as well as wound infection, yet flap hematoma was less common. On the other hand, SIEA flaps showed the lowest risk of donor site hernia/bulging while still having a high risk of wound infection. Conclusion. fTRAM procedures comparatively had the least complications. However, regarding flap choice, patients would benefit most from a case-by-case analysis, taking into consideration individual risk factors and preferences.

Analysis of 461 Consecutive Patients’ Donor Site Morbidity following Abdominal Tissue-Based Breast Reconstruction without Fascia Reinforcement Graft

Despite the popularity of breast reconstruction with abdominal flap, the integrity of the abdominal wall gets compromised after the operation. To decrease donor site morbidity, researchers have developed various inlay or onlay graft materials. However, the indications of use are unclear and dependent on the subjective decision of the surgeons. In this study, we have investigated donor site morbidities in breast reconstruction with free abdominal flap surgery in which graft materials were not used. We reviewed 461 consecutive cases for the preoperative characteristics of patients, intraoperative details, and postoperative donor site complications from May 2013 to March 2019. While 386 patients underwent deep inferior epigastric perforators (83.7%), muscle sparing type 2 transverse rectus abdominis musculocutaneous flaps were performed in 75 patients (16.3%). Bilateral dissection of the pedicle was performed in 162 patients, compared to unilateral dissection in 299 patients. The mean follow-up duration was 22.7 months. The overall complication rate in the donor site was 7.2%. The flap height was significantly associated with the overall complication. While majority of them were delayed wound healing ( $n=28$ , 6.1%), there were four cases of hematoma (0.9%). There were two cases of bulging (0.4%), which occurred in patients receiving bipedicle dissection; however, there was no case of hernia. Conclusions. Breast reconstruction with an abdominal free flap can be safely performed without fascia reinforcement graft even with bilateral dissection of the pedicle. With complete preservation of fascia and zigzag fascial incision, a low incidence of abdominal bulging can be obtained even with bilateral harvesting of the flap.

Relationship between Preoperative Abdominal Wall Strength and Bulging at the Abdominal Free Flap Donor Site for Breast Reconstruction

BACKGROUND

Abdominal bulging at the donor site of free abdominal flaps for breast reconstruction is a common postoperative complication. In addition to the thickness of abdominal muscles, the authors identified the rectus abdominis diastasis as an important factor that compromises abdominal wall strength. This study aimed to assess the relationship between preoperative abdominal wall strength and postoperative abdominal bulging.

METHODS

A total of 224 patients were enrolled in this study. Patient demographics, the rectus and lateral abdominis muscle thicknesses, and the rate of rectus abdominis diastasis were compared (with versus without bulging). Muscle thickness and rectus abdominis diastasis were investigated by preoperative computed tomography.

RESULTS

The group with bulging consisted of 32 patients (14.3 percent), whereas the group without bulging consisted of 192 patients. The group with bulging had a significantly higher gestational history rate. The thickness of the rectus abdominis muscle in the group with bulging was significantly thinner (median, 8.6 mm versus 10.5 mm; p < 0.001) and the rate of rectus abdominis diastasis was significantly higher (78.1 percent versus 32.3 percent; p < 0.001). There were no significant differences with respect to the thickness of the lateral abdominal muscle and the other factors (i.e., age, body mass index, history of laparotomy. and operative details).

CONCLUSIONS

Because the diagnosis of abdominal bulging was based on severity, the rate may be high compared to that reported from previous studies. Because the factor of gestational history correlated to thickness of the rectus abdominis muscle and rectus abdominis diastasis, this factor influenced the occurrence of abdominal bulging. Patients with a thin rectus abdominis muscle and rectus abdominis diastasis were at higher risk of abdominal bulging.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

The Rectus Abdominis Perforator Turndown Flap for Preserving Rectus Continuity: A DIEP Alternative?

The deep inferior epigastric artery perforator (DIEP) flap for breast reconstruction has been popularized over the transverse rectus abdominis myocutaneous (TRAM) flap, as it spares rectus abdominis muscle and has low donor site morbidity. This progression to muscle preservation, however, has been associated with an increased difficulty in vascular dissection, perfusion-related complications, and lengthier surgical times. We pilot a technique that may achieve the benefits of the TRAM flap in terms of ease of dissection and vascularity, with the benefits of the DIEP flap in terms of maintaining rectus abdominis continuity.

Limiting the fascia incision length in a DIEP flap: Repercussion on abdominal wall morbidity

BACKGROUND

The evolution from free muscle-sparing transverse rectus abdominis myocutaneous flap to deep inferior epigastric perforator (DIEP) flap leads to less donor-site morbidity. However, rectus fascia is usually incised longitudinally from perforator(s) to iliac vessels, often exceeding 15 cm when including longitudinal muscle spreading. By using a limited fascia incisional (LFI-) technique, we try to diminish abdominal wall functional decrease.

METHODS

Twenty-seven patients who underwent unilateral breast reconstructions using free DIEP-flap with limited fascia incision between December 2014 and October 2017 were included in the study. Each patient received a periumbilical electromyogram (EMG) preoperatively, at 6 and 14 weeks postoperatively. They were compared with 27 patients having unilateral breast reconstructions using classic free DIEP-flap, performed at the same department between November 2009 and May 2011.

RESULTS

In our LFI-technique, one vertical (4 cm) incision is made where the pedicle exits the muscle. A second, oblique (3 cm) incision is made more distally where the pedicle runs into the iliac vessels. After release, the pedicle is tunneled through the incisions, leaving all fascia, and therefore muscle, intact. In the LFI-group small neurogenic changes were noticed in only 26% and 11% of the patients at, respectively, 6 and 14 weeks postoperatively. By contrast, in the control group, postoperative neurogenic deviations remained in 37% of the patients at 14 weeks postoperatively; significant different compared to the LFI-group.

CONCLUSION

This study shows the importance of preserving anterior rectus fascia. Nerve supply and abdominal rectus muscle function are less endangered using small segmental fascia incisions. We believe that our technique diminishes donor-site morbidity significantly and improves the postoperative recovery.

The utility of free abdominal flap without Zone 4 procedure for unilateral breast reconstruction

BACKGROUND

The perfusion concept of free abdominal flap for breast reconstruction shares the common perception. We believed that free abdominal flap without Zone 4 could be performed. The purpose of this study is to introduce the "without Zone 4 procedure" and compare with the conventional technique (without 4 vs. conventional groups).

METHODS

The "without 4 group" included 61 patients, while the conventional group 55 patients. The inclusion criterion for the "without Zone 4 procedure" was defined as the thickest part of flap was more than half of the contralateral breast projection. The centerline of the skin island was adjusted to the position with the most medial side of the perforator. We compared basic characteristics (age, BMI, operation time, blood loss, contralateral breast size, smoking status, and history of laparotomy), the flaps' horizontal and vertical widths, thickness of the thickest part of the flap, elevated flap weight, and operative procedure.

RESULTS

The mean length of the flaps' horizontal width was significantly shorter (19.2 cm vs. 26.3 cm; p < .001) and the mean flap thickness was significantly greater in the without 4 group. The mean contralateral breast height and projection length were significantly longer in the conventional group. No significant differences were found with respect to the other characteristics.

CONCLUSIONS

Patients with a lower breast projection compared with the abdominal fat thickness could undergo reconstruction with a shorter flap horizontal width. Because of the esthetic outcome of the donor site, this procedure is more appropriate for low-BMI patients.

A comparative study for the rate of adverse outcomes in unilateral and bilateral abdominal flap breast reconstruction: A meta-analysis

BACKGROUND

Adverse outcomes after unilateral vs bilateral breast reconstruction involve an unknown level of risk that warrants thorough investigation.

METHODS

To address this research need, PubMed, Ovid, Medline, EMBASE, and Scopus databases were searched through systematically from January 1, 1990, to January 1, 2019 to retrieve the relevant studies on the risk of postoperative complications after unilateral vs bilateral abdominal flap breast reconstruction. According to the pre-designed inclusion criteria, available data were extracted from the relevant studies, and then analyzed comparatively in order to identify the relative risk (RR) and 95% confidence intervals (CI) applying either a random or a fixed effects model.

RESULTS

Eventually, 20 studies involving 8122 female subjects met the inclusion criteria. It was found that unilateral reconstruction involved a significantly higher risk of flap loss (RR: 1.56, 95% CI: 1.21-2.00; P < .05) and fat necrosis (RR: 1.60, 95% CI: 1.23-2.09; P < .05) compared to bilateral reconstruction, while bilateral reconstruction involved a greater risk of abdominal hernia/bulge (RR: 1.67, 95% CI: 1.25-2.24; P < .05). The risk was found to be higher following bilateral free transverse rectus abdominis myocutaneous (fTRAM) flaps in comparison with deep inferior epigastric perforator (DIEP) flaps (RR: 2.62, 95% CI: 1.33-5.15; P < .05).

CONCLUSION

The risk of postoperative flap complications in unilateral breast reconstruction is significantly higher than that in bilateral reconstruction. Contrarily, the abdominal complications were significantly higher in the bilateral group vs the unilateral group. Meanwhile, the risk of abdominal hernia/bulge complication after bilateral breast reconstruction was significantly higher with fTRAM vs DIEP. Therefore, DIEP flaps are recommended in priority for bilateral breast reconstruction, unless specifically contraindicated.

Assessment of the risk of bulge/hernia formation after abdomen-based microsurgical breast reconstruction with the aid of preoperative computed tomographic angiography-derived morphometric measurements

BACKGROUND

No preoperative risk assessment tool is available to predict postoperative bulge formation after abdomen-based breast reconstruction. The authors evaluated the association between clinical variables and morphometric measurements on preoperative computed tomographic (CT) angiography and postoperative abdominal wall morbidity.

METHODS

The authors evaluated all cases of postoperative bulge/hernia and normal controls in patients who underwent preoperative CT angiography and abdomen-based microsurgical breast reconstruction between July 2009 and January 2018. CT-based abdominal wall profiles, including abdominal wall protrusion, abdominopelvic cavity cross-sectional area (CSA), and abdominopelvic cavity-to-total body CSA ratio, were obtained and analyzed. A novel risk stratification scoring system to stratify the risk of bulge/hernia was developed.

RESULTS

Among 463 patients who underwent abdomen-based breast reconstruction, 23 were diagnosed as having a bulge/hernia. Age (OR 2.912; 95% CI 1.157-7.333), lateral row perforator (OR 5.065; 95% CI 1.834-13.986), and abdominal wall protrusion (OR 3.687; 95% CI 1.494-9.100) were significant risk factors associated with postoperative bulge/hernia in the multivariate analysis. Using the risk stratification scoring system, the incidence rates of postoperative bulge/hernia were 1.7%, 4.8%, and 19.0% for low-, intermediate-, and high-risk patients, respectively (p<0.001).

CONCLUSIONS

Age, lateral row perforator, and abdominal wall protrusion were significantly associated with postoperative bulge/hernia formation after abdomen-based microsurgical breast reconstruction. The authors' risk score based on the three variables may help predict and minimize donor-site morbidity.

Interdisciplinary Treatment of Breast Cancer After Mastectomy With Autologous Breast Reconstruction Using Abdominal Free Flaps in a University Teaching Hospital-A Standardized and Safe Procedure

Background: Breast cancer is the most common malignancy in women. The interdisciplinary treatment is based on the histological tumor type, the TNM classification, and the patient's wishes. Following tumor resection and (neo-) adjuvant therapy strategies, breast reconstruction represents the final step in the individual interdisciplinary treatment plan. Although manifold flaps have been described, abdominal free flaps, such as the deep inferior epigastric artery perforator (DIEP) or the muscle-sparing transverse rectus abdominis myocutaneous (ms-TRAM) flap, are the current gold standard for autologous breast reconstruction. This retrospective study focuses on the safety of autologous breast reconstruction upon mastectomy using abdominal free flaps. Methods: From April 2012 until December 2018, 193 women received 217 abdominal free flaps for autologous breast reconstruction at the University Hospital of Erlangen. For perforator mapping, we performed computed tomography angiography (CTA). Venous anastomosis was standardized using a ring pin coupler system, and flap perfusion was assessed with fluorescence angiography. A retrospective analysis was performed based on medical records, the surgery report, and follow-up of outpatient course. Results: In most cases, autologous breast reconstruction was performed as a secondary reconstructive procedure after mastectomy and radiotherapy. In total, 132 ms1-TRAM, 23 ms2-TRAM, and 62 DIEP flaps were performed with 21 major complications (10%) during hospital stay including five free flap losses (2.3%). In all cases of free flap loss, we found an arterial thrombosis as the main cause. In 24 patients a bilateral breast reconstruction was performed without free flap loss. The majority of free flaps (96.7%) did not need additional supercharging or turbocharging to improve venous outflow. Median venous coupler size was 2.5 mm (range, 1.5-3.5 mm). Conclusion: Using CTA, intraoperative fluorescence angiography, titanized hernia meshes for rectus sheath reconstruction, and venous coupler systems, autologous breast reconstruction with DIEP or ms-TRAM free flaps is a safe and standardized procedure in high-volume microsurgery centers.

Intersection-splitting Deep Inferior Epigastric Perforator Flap

Preserving a dynamic abdominal wall is the premise behind the evolution of TRAM flaps into deep inferior epigastric perforators (DIEPs). Performing a true DIEP flap requires a highly refined surgical technique and often times involves a tedious intramuscular dissection which may account for the slow, albeit steady adaptation of DIEPs in breast reconstruction. This article intends to address a scenario in which an additional perforator from a different row is needed. Based on our current knowledge of the abdominal wall and its embryology, we propose splitting the rectus abdominis muscle through the intersections while recruiting a second perforator instead of converting the procedure into MS-TRAM or performing a second anastomosis through the perforator exchange technique, APEX. This potentially saves time and simplifies the procedure while maintaining the integrity of the abdominal wall.

Should free deep inferior epigastric artery perforator flaps be considered a quality indicator in breast reconstruction?

Over the past several decades, technical advances in breast reconstruction have resulted in the development of flaps that are aimed at progressively decreasing abdominal wall morbidity. There is, however, ongoing controversy related to the superiority of deep inferior epigastric perforator (DIEP) flaps over muscle-sparing TRAM (MS-TRAM) flaps. Hence, the question remains unanswered as to which approach should be considered the standard of care, and more importantly, whether the rate of DIEP flap utilization should be considered a quality metric in breast reconstruction. In this review article, we examine the literature pertaining to abdominal free tissue transfer in breast reconstruction from both donor site and flap characteristics as well as the resultant complications and morbidity. The impact on the donor site remains a prevailing principle for autologous breast reconstruction; thus, must be adequately respected when classifying what is left behind following flap harvest. The most commonly used nomenclature is too simplistic. This, in turn, leads to inadequate incorporation of critical variables, such as degree of muscular preservation, fascial involvement, mesh implantation, and segmental nerve anatomy. Currently, there is insufficient evidence to support DIEP flap harvest as a quality indicator in breast reconstruction, as DIEP flap outcomes are not clearly superior when compared with MS-TRAM flaps.

An anatomic study of deep inferior epigastric artery diameters at the origin from external iliac and at the lateral border of rectus abdominis muscle by computed tomographic angiography from autologous breast reconstruction patients

BACKGROUND

Autologous breast reconstruction by means of microsurgical abdominal flaps is an very well described technique. The flap harvest dissection under inguinal ligament would cause the risk of parietal weakening in this zone and postoperative bulging. The goal of our study is to investigate whether the deep inferior epigastric artery diameter remains constant from its exit of the external iliac artery to its entrance in the rectus muscle sheath.

PATIENTS AND METHOD

One hundred arteries were studied on fifty preoperative computed tomographic angiographies made before a DIEAP flap for breast reconstruction. We measured the caliber of the left and right deep inferior epigastric arteries at these two landmarks. The length of this artery between these was also calculated. This data were collected with specific angiography reconstruction.

RESULTS

At the caudal landmark, the mean DIEA diameter was 2.1±0.27mm on the left side and 2.1±0.31mm on the right side. At the cephalic landmark, the mean DIEA diameter was 2.0±0.28mm on the left and 2.0±0.27mm on the right side (P=0.00035 at left side; P=0.0089 at right side). The mean pedicle length between the two landmarks was 22.3±2.85mm on the left side and 22.2±2.98mm on the right side.

CONCLUSION

This computed tomographic angiography study showed that the diameter of DIEA is equivalent at its origin and at the lateral border of muscle. Flap harvest without dissection under inguinal ligament provides sufficient pedicle length and caliber to allow for comfortable and reliable sutures.

Muscle-sparing pedicled transverse rectus abdominis myocutaneous flaps for breast reconstruction: Combining benefits of both worlds

Background:

Breast reconstruction plays a vital role in the restoration of form post-mastectomy. Autologous breast reconstructions using both free as well as pedicled flaps form the bulk of the breast reconstruction in our centre.

Objective:

This study seeks to evaluate the muscle-sparing modification of the pedicled transverse rectus abdominis myocutaneous (MS-TRAM) flaps against conventional transverse rectus abdominis myocutaneous (TRAM) flaps, in an attempt to marry the benefits of both and minimise the drawbacks of each technique.

Patients and methods:

A retrospective analysis of 20 women, 10 of whom had undergone unilateral immediate breast reconstruction with pedicled MS-TRAM flaps after skin-sparing mastectomy (MS group), and 10 who had undergone the conventional pedicled TRAM flap (control group) by the same surgeon (S. Ho) over a two-year period from 2013 to 2015 was performed. Patients’ records were reviewed, assessing patient demographics including age, smoking status and evaluating the operative time, time to ambulation, length of hospital stay, pain scores and abdominal bulge rates.

Results:

Mean operative time was not significantly longer in the MS group. Pain scores were lower in the MS group. The length of hospital stay was not significantly different between the two groups. Abdominal bulge rates at 24 months postoperatively were 0% in the MS group patients and 10% in the control group.

Conclusion

The pedicled MS-TRAM flap is an excellent breast reconstruction option that is comparable to the conventional TRAM flap. It preserves innervated muscle in the donor site that reduces time to ambulation and postoperative pain. It does not add significantly to surgical time and does not require microvascular anastomosis.

Donor-site morbidities in 615 patients after breast reconstruction using a free muscle-sparing type I transverse rectus abdominis myocutaneous flap: a single surgeon experience

Transverse rectus abdominis myocutaneous flap is one of the most commonly used reconstruction tools after oncological mastectomy. However, post-operative donor-site morbidities remain an issue to be addressed. In this study, we retrospectively reviewed patients with either immediate or delayed breast reconstruction using a free muscle-sparing type I transverse rectus abdominis myocutaneous flap only, performed by a single surgeon, regarding the donor-site morbidity. From January 2012 to July 2017, the study subjects summed up to 615 patients, in a single institution. Preoperative planning and actual surgical techniques were outlined including the evaluation of the location of the perforators using a three-dimensional abdominal computed tomography angiography scan, minimal fascia sacrifice, beveled dissection and minimization of the tension on the central abdomen during closure. During a 1-year follow-up, a total of 33 patients (5.4%) were complicated with any donor-site morbidity. Those in need of secondary revision on their donor-sites accounted for 23 patients (69.7%). No factor was found statistically significant to increase the risk of donor-site morbidity. Many surgical techniques have been devised for closure of the donor-site in transverse rectus abdominis myocutaneous flap patients. And, several factors have been proposed as increasing the risk of donor-site morbidity. Although all the suggested predictive factors failed to prove its significance on increasing the risk, a set of preoperative planning and surgical techniques employed in our study has proven to be both safe and efficient in lowering the postoperative donor-site morbidities.

Volume change in the rectus abdominis muscle after deep inferior epigastric perforator flap harvest

Deep inferior epigastric perforator (DIEP) flap is associated with less donor site morbidity than transverse rectus abdominis myocutaneous flap. However, abdominal muscle atrophy and donor site complications caused by denervation during pedicle dissection cannot be avoided. This retrospective study investigated the change in the rectus abdominis muscle volume after DIEP flap harvest. Of 395 patients who underwent unilateral DIEP flap breast reconstruction between August 2007 and July 2017, 25 patients with >2-year postoperative abdominal computed tomography data were evaluated. Preoperative and postoperative images of the abdominal muscle after pedicle dissection and the nonoperated side were compared. The volume of the muscles from the lower margin to the umbilicus was determined by using OsiriX image analysis application. The muscle volumes on the side of pedicle dissection decreased from 72.63 ± 23.29 cm³ preoperation to 53.09 ± 16.93 cm³ postoperation (p < 0.001). The corresponding volumes on the side without dissection were 73.29 ± 19.25 cm³ and 60.89 ± 18.79 cm³ (p < 0.001). The percentage of postoperative retained volume relative to the preoperative retained volume was 75.65% ± 19.18% on the pedicle dissection side and 84.65% ± 19.00% on the contralateral side. The 9% difference was not statistically significant (p = 0.10). No major abdominal complications were observed. Despite nerve injury during DIEP flap surgery, the volume loss of the involved and contralateral muscles did not differ. More than 75% of the abdominal muscle volume was retained. Muscle integrity was well maintained without any postoperative complications.

Deep Inferior Epigastric Perforator Versus Free Transverse Rectus Abdominis Myocutaneous Flap: Complications and Resource Utilization

INTRODUCTION

Abdominal based breast reconstruction exists in a continuum from pedicled transverse rectus abdominis myocutaneous (TRAM) flap to deep inferior epigastric perforator (DIEP) free flap. DIEP flap has the advantage of complete rectus abdominis sparing during harvest, thus decreasing donor site morbidity. Aim of this study is to determine whether the surgical advantages of the DIEP flap impact postoperative outcomes versus the free TRAM flap (fTRAM).

METHODS

We reviewed the Nationwide Inpatient Sample database (2010-2011) for all cases of DIEP and fTRAM breast reconstruction. Inclusion criteria were: female sex and patients undergoing DIEP or fTRAM total breast reconstruction. Male sex was excluded from the analysis. We examined demographic characteristics, hospital setting, insurance information, patient income, comorbidities, postoperative complications (including reoperation, hemorrhage, hematoma, seroma, myocardial infarction, pulmonary embolus, wound infection, and flap loss), length of stay, and total charges (TCs). Bivariate and multivariate analyses were performed to identify independent risk factors of increased length of stay and TCs.

RESULTS

Fifteen thousand eight hundred thirty-six cases were identified. Seventy percent were white, 97% were insured, and 83% of patients were treated in an academic teaching hospital setting. No mortalities were recorded. The DIEP cohort was more likely to be obese (P = 0.001). Free TRAM cohort was more likely to suffer pneumonia (P < 0.001; odds ratio [OR], 3.7), wound infection (P = 0.001; OR, 1.7), and wound dehiscence (P < 0.001; OR, 4.3). Type of reconstruction did not appear to affect risk of revision, hemorrhage, hematoma, seroma, or flap loss. Total charges were higher in the DIEP group (P < 0.001). Multivariate analysis demonstrated that fTRAM was an independent risk factor for increased length of stay (P < 0.001; OR, 1.6), and DIEP was an independent risk factor for increased TCs (P < 0.01; OR, 1.5). There was no significant difference in postoperative complications.

CONCLUSIONS

The fTRAM cohort was more likely to develop surgical site complications and have an increased length of stay, but TCs were higher for the DIEP group.

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..

Effects of High-Voltage Electrical Stimulation in Improving the Viability of Musculocutaneous Flaps in Rats

BACKGROUND

The musculocutaneous flap of the transverse rectus abdominis muscle is a technique used for breast reconstruction, and one of the complications of this procedure is tissue necrosis. The objective of the study is to determine the effect of high-voltage electrical stimulation (HVES) in the transverse rectus abdominis muscle flap in rats.

METHODS

Fourteen rats underwent surgery for obtaining the flap. The rats were distributed into 2 homogeneous groups: group 1 underwent both surgery and the use of HVES, whereas group 2 underwent just the surgery (control). Electrical stimulation was applied immediately after surgery and for 2 consecutive days. The percentage of necrotic area was analyzed using the Image J software, and blood flow was assessed by infrared thermography in different regions of the flap, divided into 4 zones according to the proximity of the pedicle of the inferior epigastric artery.

RESULTS

The results were analyzed using a Student t test, where group 1 experienced a necrotic area of 26.2%, and group 2 had an area of 54.5%. Regarding the temperature, the 2 groups showed increase in the minimum and maximum temperature on the fourth postoperative day.

CONCLUSION

The HVES appeared to have a positive influence on the viability of the flap.

Donor-Site Morbidity After DIEAP Flap Breast Reconstruction-A 2-Year Postoperative Computed Tomography Comparison

The study was undertaken to provide a more complete picture of donor-site morbidity following the deep inferior epigastric artery perforator (DIEAP) flap harvest in breast reconstruction. Most studies evaluating this subject have been performed using ultrasonography. Computed tomography (CT) might provide valuable information.

Preoperative Computed Tomographic Angiogram Measurement of Abdominal Muscles Is a Valuable Risk Assessment for Bulge Formation after Microsurgical Abdominal Free Flap Breast Reconstruction

BACKGROUND

A major shortcoming associated with abdominal tissue breast reconstruction is long-term abdominal wall morbidity. Although abdominal muscle size on computed tomographic angiography has been correlated with morbidity following many abdominal operations, it has not been studied for breast reconstruction. Therefore, the authors evaluated the association between preoperative computed tomography angiography-derived measurements of abdominal core muscles and postoperative abdominal wall morbidity after abdominal tissue breast reconstruction.

METHODS

In this retrospective matched case-control study of women who underwent microsurgical abdominal flap breast reconstruction at one institution between January 2011 and June 2015, the authors evaluated all cases of postoperative bulge/hernia, matched by type of abdominal flap and body mass index in a ratio of 1:2 to controls without bulge/hernia. The authors obtained morphometric measurements of abdominal core muscles on preoperative computed tomographic angiographs. Using univariable and multivariable logistic regressions, the authors examined the effects of clinical risk factors and computed tomographic angiography morphometric measurements on postoperative bulge/hernia formation.

RESULTS

Of the 589 patients who underwent abdominal free flap breast reconstruction, symptomatic bulges/hernias were identified in 35 patients (5.9 percent). When compared to the 70 matched controls, multivariable analysis showed that decreased area of rectus abdominis muscle (OR, 0.18; p < 0.01) and increased inter-rectus abdominis distance (OR, 1.14; p < 0.01) on computed tomographic angiography were significant risk factors associated with postoperative bulge/hernia.

CONCLUSION

Preoperative computed tomographic angiography allows objective measurements of the patient's abdominal muscle anatomy that provide valuable prognostic information on the risk of bulge/hernia formation following abdominally based microsurgical breast reconstruction.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

Low-intensity pulsed ultrasound stimulation in different regions in the viability of myocutaneous flaps

Background

Low-intensity pulsed ultrasound (LIPUS) has presented good results in the healing of chronic wounds. The objective of this study was to compare the effect of LIPUS on the viability of transverse rectus abdominal muscle (TRAM) flap in different regions (central and epigastric) in rats.

Methods

Twenty-one Wistar male rats were homogeneously distributed into three groups as follows: group 1 (control), animals submitted to surgery only; group 2, animals submitted to surgery and application of LIPUS at the center of the flap; and group 3, animals submitted to surgery and application of LIPUS at the flap area corresponding to the right inferior epigastric artery pedicle. Stimulation was performed immediately after the surgery and within the following 2 days. The percentage of flap necrosis was evaluated by using the ImageJ® software as well as by measuring the temperature variation with infrared thermography (FLIR® T300).

Results

In the percentage calculation of the necrosis area, the application of LIPUS at the center of the flap (group 2) showed significantly smaller difference (26.2 %) compared to group 1 (54.50 %) and group 3 (44.01 %). Analysis of the temperature variation between the groups was performed by using the one-way ANOVA followed by Tukey’s test. The results showed that both forms of LIPUS application showed significant differences compared to the control group.

Conclusions

In view of our results, one can conclude that the application of LIPUS at the center of the flap was effective for the viability of TRAM flap in reducing the necrosis area.

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.

Quality of Life and Patient-Reported Outcomes in Breast Cancer Survivors: A Multicenter Comparison of Four Abdominally Based Autologous Reconstruction Methods

BACKGROUND

Approximately 20 percent of women select autologous tissue for postmastectomy breast reconstruction, and most commonly choose the abdomen as the donor site. An increasing proportion of women are seeking muscle-sparing procedures, but the benefit remains controversial. It is therefore important to determine whether better outcomes are associated with these techniques, thereby justifying longer operative times and increased costs.

METHODS

Patients from five North American centers were eligible if they underwent reconstruction by means of the deep inferior epigastric artery perforator (DIEP) flap, muscle-sparing free transverse abdominis myocutaneous (TRAM) flap, free TRAM flap, or the pedicled TRAM flap. Patients were sent the BREAST-Q. Demographics and complications were collected.

RESULTS

The authors analyzed 1790 charts representing 670 DIEP, 293 muscle-sparing free TRAM, 683 pedicled TRAM, and 144 free TRAM patients with an average follow-up of 5.5 years. Flap loss did not differ by flap type. Partial flap loss was higher in pedicled TRAM compared with DIEP (p = 0.002). Fat necrosis was higher in pedicled TRAM compared with DIEP and muscle-sparing free TRAM (p < 0.001). Hernia/bulge was highest in pedicled TRAM (p < 0.001). Physical well-being (abdomen) scores were higher in DIEP compared with pedicled TRAM controlling for confounders.

CONCLUSIONS

Complications and patient-reported outcomes differ when comparing abdominally based breast reconstruction techniques. The results of this study show that the DIEP flap was associated with the highest abdominal well-being and the lowest abdominal morbidity compared with the pedicled TRAM flap, but did not differ from muscle-sparing free TRAM and free TRAM flaps.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Bipedicled DIEAP flaps for reconstruction of limb soft tissue defects in male patients

BACKGROUND

Extensive soft tissue deficiencies involving the limbs can be difficult to reconstruct and may require more than one microsurgical flap transfer to cover the defect. This can be particularly challenging in male patients, where the sacrifice of a donor muscle could result in considerable comorbidity. This paper describes the use of the bipedicled deep inferior epigastric artery perforator (DIEAP) flap to perform a one-stage reconstruction of extensive soft tissue defects in male patients.

METHODS

By using preoperative multidetector computed tomographic (MDCT) angiography, the dominant perforators of the abdominal wall were identified and the bipedicled DIEAP flap was used for a one-stage reconstruction of complicated tissue loss in 12 male patients. In seven of these flaps, a microsurgical anastomosis between the two epigastric pedicles of the DIEAP flap was carried out. The feasibility of the procedure, clinical outcome, and possible associated comorbidities were evaluated.

RESULTS

Successful large tissue reconstructions were performed using all four traditional zones of the DIEAP flap, with dimensions of flaps ranging from 20 × 8 to 50 × 17 cm. Venous congestion was seen to develop in two flaps, one of which was salvaged by performing an additional venous anastomosis, but the other flap failed to survive. Apart from this, complications were minimal.

CONCLUSIONS

Soft tissue coverage of extensive wounds in male patients without sacrificing muscle flaps can be challenging. This extended utilization of the entire DIEAP flap has helped us to address this issue.

Increasing options in autologous microsurgical breast reconstruction: four free flaps for 'stacked' bilateral breast reconstruction

For autologous breast reconstruction, there are cases where one free flap cannot provide the volume of tissue required, and the concept of 'stacked' bilateral deep inferior epigastric artery (DIEP) flaps was developed, in which hemi-abdominal flaps are raised on each deep inferior epigastric artery (DIEA), and both flaps transferred to the chest. In cases of bilateral breast reconstruction, stacked flaps may be required to achieve volume replacement, however options are not described. We demonstrate the use of stacked free flaps for bilateral breast reconstruction, using one DIEP flap stacked with one transverse upper gracilis (TUG) flap for each side. A 49-year-old woman, with BRCA1 mutation, presented for risk reduction mastectomies. Flap design was planned to achieve maximal projection and primary nipple reconstruction. This was able to be achieved by using the DIEP flap de-epithelialised and completely buried, with the flap orientated with the pedicle on its superficial surface, and the TUG flap lying superficially with its skin paddle used for nipple reconstruction and able to be monitored clinically. There were no flap or donor related complications and good aesthetic outcomes were achieved. This technique offers a further option in microsurgical breast reconstruction for patients in whom there is a paucity of abdominal tissue for reconstruction.

Stacked and bipedicled abdominal free flaps for breast reconstruction: considerations for shaping

BACKGROUND

Stacked and bipedicled abdominal flaps are useful in women who require a large breast reconstruction but have relative paucity of abdominal tissue. A new classification system is described to assist the surgeon in achieving the best possible aesthetic outcome.

METHODS

A retrospective review of 25 consecutive stacked and/or bipedicled deep inferior epigastric perforator (DIEP) flap reconstructions was assessed from 2009 to 2014. Demographic data and key variables were prospectively collected in our breast reconstruction database and an aesthetic classification devised. There are four main subtypes, (I) folded; (II) divided; (III) coned; and (IV) divided and folded. Each of these subtypes can be moulded in a symmetrically or asymmetrically fashion depending on the contralateral breast shape together with distribution and consistency of fat within the abdominal flap.

RESULTS

Of the 25 patients, three-quarter were immediate reconstruction, with an average age of 48 years and a median follow-up of 2 years 10 months. Just over half the patients (57%) had bipedicle flaps with two recipient donor vessels with the remaining 43% had stacked flaps. The most common recipient sites are the thoracodorsal vessels (62%) and intercostal perforators (26%). The average abdominal pannus weight was 610 grams (SD: 320 grams), with a hemi-abdominal weight of 305 grams. Two patients had haematomas, of which one lost their reconstruction. Another patient had a venous congestion flap which was salvaged.

CONCLUSIONS

Bipedicled or stacked abdominal flaps allow the all four zones of the abdominal tissue to be used in unilateral breast reconstruction. The approach of tailoring the abdominal flaps to match the contralateral breast reconstruction is largely an art form. The paper aims to bring some meaningful system to aid the surgeon to achieve the best possible outcome with the components presented to them.

Flap Failure and Wound Complications in Autologous Breast Reconstruction: A National Perspective

PURPOSE

There are many options for breast reconstruction following a mastectomy, and data on outcomes are greatly needed for both the patient and the care provider. This study aims to identify the prevalence and predictors of adverse outcomes in autologous breast reconstruction in order to better inform patients and surgeons when choosing a surgical technique.

METHODS

This study retrospectively reviewed the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) and identified each autologous breast reconstruction performed between 2005 and 2012. Of the 6855 autologous breast reconstructions, there were 2085 latissimus dorsi (LD) flap procedures, 2464 pedicled transverse rectus abdominis myocutaneous (TRAM) flap procedures, and 2306 free flap procedures that met the inclusion criteria. The prevalence of complications in each of the three procedures was calculated and compared using χ(2) analysis for binomial categorical variables. Univariate and multivariate logistic regression analyses identified independent risk factors for adverse outcomes in autologous reconstruction as a whole.

RESULTS

The prevalence of general complications was 10.8% in LD flaps, 20.6% in TRAM flaps, and 26.1% in free flaps for autologous breast reconstruction (p < 0.001). The prevalence of wound complications was 4.3% in LD flaps, 8.1% in TRAM flaps, and 6.2% in free flaps for autologous breast reconstruction (p < 0.001). The prevalence of flap failure was 1.1 % in LD flaps, 2.7% in TRAM flaps, and 2.4% in free flaps for autologous breast reconstruction (p < 0.001). Multivariate regression analysis showed that obesity [odds ratio (OR) 1.495, p = 0.024], hypertension (OR 1.633, p = 0.008), recent surgery (OR 3.431, p < 0.001), and prolonged operative times (OR 1.944, p < 0.001) were independently associated with flap failure in autologous breast reconstruction procedures. When controlling for confounding variables, TRAM flaps were twice as likely (OR 2.279, p = 0.001) and free flaps were three times as likely (OR 3.172, p < 0.001) to experience flap failure when compared to LD flaps.

CONCLUSIONS

Latissimus dorsi flaps are associated with the fewest short-term general complications and free flaps are associated with the most short-term general complications in autologous breast reconstruction. Free flaps are the most likely to experience flap failure, though there is no significant difference when compared to pedicled TRAM flaps. Free and TRAM flaps remain as the widely acceptable forms of breast reconstruction in the patient without many risk factors for flap failure or wound complications. The identified risk factors will aid in surgical planning and risk adjustment for both the patient and the care provider. Though many other factors will be taken into consideration with surgical planning of autologous breast reconstruction, the presence of these identified risk factors may encourage the use of a surgical technique associated with fewer adverse outcomes, like the LD flap.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Donor site morbidity following DIEP flap for breast reconstruction in Asian patients: Is it different?

BACKGROUND

Despite the decrease in donor-site morbidity with the advent of deep inferior epigastric artery perforator (DIEP) flap breast reconstruction, abdominal complications still occur. There have been few studies on donor morbidity considering the ethnic differences in the Asian population, as represented by a lower BMI with less redundant tissue and a tendency for poor scarring. In the present study, the authors investigated the incidence of abdominal complications and their risk factors following DIEP flap breast reconstruction in an Asian population.

PATIENTS AND METHODS

The authors conducted a retrospective review of DIEP flap based breast reconstructions performed in the past 5 years. Data regarding patient demographics, surgical details, and abdominal complications were collected from our prospectively maintained database and analyzed.

RESULTS

A total of 217 patients who underwent DIEP flap breast reconstruction were included. There were 51 abdominal complications (23.5%), including 18 delayed wound healing, 17 hypertrophic scarring, 12 seroma formation, and 8 abdominal bulges with no hernias. Secondary procedures were performed for the donor-site complications in 36 cases. Flap height was a significant risk factor for overall donor-site morbidity. Harvesting a bipedicle flap was significantly associated with abdominal fat necrosis and hypertrophic scarring. Harvesting a flap based on perforators from both rows was significantly associated with abdominal delayed wound healing and hypertrophic scarring.

CONCLUSIONS

DIEP flap breast reconstruction performed in Asian patients showed acceptable donor-site morbidity without significant complications. This study suggests that donor-site morbidity from harvesting a DIEP flap is comparable to that described in Western literatures.

Donor-Site Hernia Repair in Abdominal Flap Breast Reconstruction: A Population-Based Cohort Study of 7929 Patients

BACKGROUND

The authors investigated hernia repair rates following pedicled transverse rectus abdominis myocutaneous (TRAM), free TRAM, and deep inferior epigastric perforator (DIEP) flap breast reconstruction in English National Health Service hospitals.

METHODS

Women diagnosed with breast cancer who underwent pedicled TRAM, free TRAM, or DIEP flap breast reconstruction procedures in English National Health Service hospitals between April of 2006 and March of 2012 were identified using the Hospital Episode Statistics database. Women who underwent mastectomy without reconstruction acted as controls, and hernia repair rates were calculated for all four groups. Multiple Cox regression was performed to estimate the relative risk of hernia repair among the reconstruction groups, adjusted for age, obesity, previous abdominal surgery, reconstruction year, and bilateral flap harvest.

RESULTS

Between 2006 and 2012, 7929 women had a DIEP or TRAM flap breast reconstruction. The overall hernia repair rate within 3 years was 2.45 percent after abdominal flap breast reconstruction, and 0.28 percent among the 15,679 women who had mastectomy only. Mean time to hernia repair following an abdominal flap harvest was 17.7 months. Compared with DIEP flaps, free and pedicled TRAM flap procedures were associated with adjusted hazard ratios of 1.81 (95 percent CI, 1.24 to 2.64) and 2.89 (95 percent CI, 1.91 to 4.37), respectively. The only independent risk factor for hernia repair was age older than 60 years (p = 0.039).

CONCLUSIONS

Abdominally based autologous breast reconstruction carries a small risk of subsequent donor-site hernia repair. The rates herein can be used to inform patients and to assess quality of care across service providers.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Satisfaction following Unilateral Breast Reconstruction: A Comparison of Pedicled TRAM and Free Abdominal Flaps

Background:

The purpose of this study was to compare patient satisfaction following unilateral pedicled transverse rectus abdominis myocutaneous (TRAM) and free abdominal flap reconstruction.

Methods:

Patients who underwent unilateral breast reconstruction using pedicled TRAM or free abdominal flaps (muscle-sparing TRAM or deep inferior epigastric perforator flap) and completed the BREAST-Q were identified from 2 prospectively maintained databases. BREAST-Q scores were assessed and compared for Satisfaction with Breasts, Outcome, and Physical Well-being Chest/Abdomen.

Results:

Of the 138 patients who completed the BREAST-Q, 84 underwent pedicled TRAM flap reconstruction and 54 underwent free abdominal flap reconstruction. Overall, pedicled TRAM flap patients scored higher than free abdominal flap patients on all 4 BREAST-Q scales. This difference reached statistical significance in Satisfaction with Breasts (+7.74; P = 0.02). Similar results were found among patients who completed the BREAST-Q at <3 years postoperation. However, among patients at ≥3 years postoperation, there were no statistically significant differences between the 2 groups, with the pedicled flap cohort scoring higher in Satisfaction with Breasts and Physical Well-being Chest and the free abdominal flap cohort scoring higher in Satisfaction with Outcome and Physical Well-being Abdomen scores.

Conclusions:

Patients who underwent unilateral pedicled TRAM flap reconstruction experienced greater initial breast satisfaction than patients who underwent unilateral free abdominal flap reconstruction, but satisfaction equalized between the two over time, suggesting that long-term satisfaction may be equivalent between the 2 methods of reconstruction.