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Beugels J, Levine JL, Vasile JV, Craigie JE, Allen RJ. The Delay Procedure in Deep Inferior Epigastric Artery Perforator Flap Breast Reconstruction. Plast Reconstr Surg 2024; 153:1063e-1072e. [PMID: 37335555 DOI: 10.1097/prs.0000000000010837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/21/2023]
Abstract
BACKGROUND The delay procedure in deep inferior epigastric artery perforator (DIEP) flap breast reconstruction, in which the reduced-caliber choke vessels play a major role, can provide more well-perfused tissue than a standard DIEP flap. The aim of this study was to review the authors' experience with this technique, evaluate the indications, and analyze the surgical outcomes. METHODS A retrospective study was conducted of all consecutive DIEP delay procedures performed between March of 2019 and June of 2021. Patient demographic characteristics, operative details, and complications were registered. Patients had preoperative imaging by magnetic resonance angiography to select dominant perforators. The surgical technique involves a two-stage operation. During the first operation, the flaps were pedicled on a dominant perforator and a lateral skin bridge extending toward the lateral flank and lumbar fat; in a second stage, the flap was harvested and transferred. RESULTS A total of 82 extended DIEP delay procedures were performed to reconstruct 154 breasts. The majority were bilateral breast reconstructions (87.8%). The delay procedure was used for 38 primary reconstructions (46.3%) and 32 tertiary reconstructions (39.0%). The primary indication was the need for additional volume (79.3%), followed by extensive abdominal scarring and liposuction. After the first operation, seroma was the most frequently observed complication (7.3%). After the second operation, three total flap losses (1.9%) were observed. CONCLUSIONS The delay procedure in DIEP flap breast reconstruction results in the harvest of a good amount of abdominal tissue by adding a preliminary procedure. This technique can convert cases previously considered unsuitable into suitable candidates for abdominal-based breast reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.
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Affiliation(s)
- Jop Beugels
- From the Department of Plastic, Reconstructive, and Hand Surgery
- GROW School for Oncology and Developmental Biology, Maastricht University Medical Center
| | | | - Julie V Vasile
- Center for Breast Reconstruction
- Division of Plastic Surgery, Northern Westchester Hospital
| | | | - Robert J Allen
- Division of Plastic Surgery, Louisiana State University Health Sciences Center
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Fisher MH, Ohmes LB, Yang JH, Le E, Colakoglu S, French M, Siddikoglu D, Um G, Winocour J, Higdon K, Perdikis G, Inchauste S, Cohen J, Chong T, Kaoutzanis C, Mathes DW. Abdominal donor-site complications following autologous breast reconstruction: A multi-institutional multisurgeon study. J Plast Reconstr Aesthet Surg 2024; 90:88-94. [PMID: 38364673 DOI: 10.1016/j.bjps.2024.01.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 12/13/2023] [Accepted: 01/29/2024] [Indexed: 02/18/2024]
Abstract
BACKGROUND The deep inferior epigastric perforator (DIEP) free flap is the gold standard procedure for autologous breast reconstruction. Although breast-related complications have been well described, donor-site complications and contributing patient risk factors are poorly understood. METHODS We examined a multi-institutional, prospectively maintained database of patients undergoing DIEP free flap breast reconstruction between 2015 and 2020. We evaluated patient demographics, operative details, and abdominal donor-site complications. Logistic regression modeling was used to predict donor-site outcomes based on patient characteristics. RESULTS A total of 661 patients were identified who underwent DIEP free flap breast reconstruction across multiple institutions. Using logistic regression modeling, we found that body mass index (BMI) was an independent risk factor for umbilical complications (odds ratio [OR] 1.11, confidence interval [CI] 1.04-1.18, p = 0.001), seroma (OR 1.07, CI 1.01-1.13, p = 0.003), wound dehiscence (OR 1.10, CI 1.06-1.15, p = 0.001), and surgical site infection (OR 1.10, CI 1.05-1.15, p = 0.001) following DIEP free flap breast reconstruction. Further, immediate reconstruction decreases the risk of abdominal bulge formation (OR 0.22, CI 0.108-0.429, p = 0.001). Perforator selection was not associated with abdominal morbidity in our study population. CONCLUSIONS Higher BMI is associated with increased abdominal donor-site complications following DIEP free flap breast reconstruction. Efforts to lower preoperative BMI may help decrease donor-site complications.
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Affiliation(s)
- Marlie H Fisher
- Department of Plastic and Reconstructive Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Lucas B Ohmes
- Department of Plastic and Reconstructive Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Jerry H Yang
- Department of Plastic and Reconstructive Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Elliot Le
- Department of Plastic and Reconstructive Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Salih Colakoglu
- Department of Plastic and Reconstructive Surgery, Johns Hopkins Medicine, Baltimore, MD, United States
| | - Mackenzie French
- Department of Plastic and Reconstructive Surgery, University of Washington, Seattle, WA, United States
| | - Duygu Siddikoglu
- Department of Biostatistics, Canakkale OnSekiz Mart Faculty of Medicine, Canakkale, Turkey
| | - Grace Um
- Department of Plastic and Reconstructive Surgery, University of Washington, Seattle, WA, United States
| | - Julian Winocour
- Department of Plastic and Reconstructive Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Kent Higdon
- Department of Plastic and Reconstructive Surgery, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Galen Perdikis
- Department of Plastic and Reconstructive Surgery, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Suzanne Inchauste
- Department of Plastic and Reconstructive Surgery, University of Washington, Seattle, WA, United States
| | - Justin Cohen
- Department of Plastic and Reconstructive Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Tae Chong
- Department of Plastic and Reconstructive Surgery, Virginia Commonwealth University, Richmond, VA, United States
| | - Christodoulos Kaoutzanis
- Department of Plastic and Reconstructive Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - David W Mathes
- Department of Plastic and Reconstructive Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, United States.
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Sacak B, Sakarya AH, Haytaoglu AA, Akdeniz Dogan Z, Ugurlu MU. Do bilateral procedures further increase the complications for autologous breast reconstruction in obese patients? Breast Cancer Res Treat 2023; 202:435-442. [PMID: 37658278 DOI: 10.1007/s10549-023-07082-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 08/10/2023] [Indexed: 09/03/2023]
Abstract
BACKGROUND Obesity is known to be associated with high complication rates. The aim of this study was to evaluate the effect of bilateral procedures on complication rates in obese patients undergoing autologous breast reconstruction with deep inferior epigastric perforator flaps. METHODS Medical records of patients undergoing autologous breast reconstruction between January 2017 and December 2019 were retrospectively reviewed. Patients were divided into two groups according to their body mass index (BMI): Group 1 (BMI > 30) and Group 2 (BMI < 30). Group 1 was further divided into 3 subgroups: Group 1a (bilateral reconstruction), Group 1b (unilateral reconstruction), and Group 1c (unilateral reconstruction and contralateral symmetrization). Outcomes and complication rates were compared between groups. RESULTS Ninety-one patients (with 119 free flaps) were followed up between 6 and 12 months. Length of hospital stay, smoking rates, and age were similar in all groups. Group 1 had significantly more rates of wound dehiscence (p = 0.024), mastectomy skin flap necrosis (p = 0.019), and re-operation (p = 0.033). The operation time was significantly higher in group 1 (p = 0.003). There was no significant difference between group 1 and group 2 in terms of hematoma-seroma formation, flap loss, and pulmonary thromboembolism rates. When obese subgroups were compared, no significant difference was observed in terms of complications. CONCLUSION In our series, microvascular breast reconstruction was associated with more complication rates in obese patients. However, bilateral procedures in the obese patient group did not significantly increase risk of complications as compared to unilateral procedures. By taking appropriate measures bilateral procedures can be performed in obese patients without additional risks.
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Affiliation(s)
- Bulent Sacak
- Department of Plastic Aesthetic and Reconstructive Surgery, Marmara University School of Medicine, Istanbul, Turkey
| | - Ahmet Hamdi Sakarya
- Department of Plastic Aesthetic and Reconstructive Surgery, Marmara University School of Medicine, Istanbul, Turkey
| | - Adem Atakan Haytaoglu
- Department of Plastic Aesthetic and Reconstructive Surgery, Marmara University School of Medicine, Istanbul, Turkey.
- Marmara University Hospital Pendik Istanbul, Fevzi Cakmak, Muhsin Yazicioglu St. No:10, Istanbul, Turkey.
| | - Zeynep Akdeniz Dogan
- Department of Plastic Aesthetic and Reconstructive Surgery, Marmara University School of Medicine, Istanbul, Turkey
| | - Mustafa Umit Ugurlu
- Department of General Surgery, Marmara University School of Medicine, Istanbul, Turkey
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Wu SS, Raymer C, Culbert A, Schafer R, Bernard S, Djohan R, Schwarz G, Bishop SN, Gurunian R. Predictors of Complications in Autologous Breast Reconstruction Using DIEP Flaps: Implications for Management. Plast Reconstr Surg 2023; 152:566e-577e. [PMID: 36862950 DOI: 10.1097/prs.0000000000010343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/04/2023]
Abstract
BACKGROUND Deep inferior epigastric perforator (DIEP) flaps are the standard for autologous breast reconstruction. This study investigated risk factors for DIEP complications in a large, contemporary cohort to optimize surgical evaluation and planning. METHODS This retrospective study included patients who underwent DIEP breast reconstruction between 2016 and 2020 at an academic institution. Demographics, treatment, and outcomes were evaluated in univariable and multivariable regression models for postoperative complications. RESULTS In total, 802 DIEP flaps were performed in 524 patients (mean age, 51.2 ± 9.6 years; mean body mass index, 29.3 ± 4.5). Most patients (87%) had breast cancer; 15% were BRCA -positive. There were 282 (53%) delayed and 242 (46%) immediate reconstructions and 278 (53%) bilateral and 246 (47%) unilateral reconstructions. Overall complications occurred in 81 patients (15.5%), including venous congestion (3.4%), breast hematoma (3.6%), infection (3.6%), partial flap loss (3.2%), total flap loss (2.3%), and arterial thrombosis (1.3%). Longer operative time was significantly associated with bilateral immediate reconstructions and higher body mass index. Prolonged operative time (OR, 1.16; P = 0.001) and immediate reconstruction (OR, 1.92; P = 0.013) were significant predictors of overall complications. Partial flap loss was associated with bilateral immediate reconstructions, higher body mass index, current smoking status, and longer operative time. CONCLUSIONS Prolonged operative time is a significant risk factor for overall complications and partial flap loss in DIEP breast reconstruction. For each additional hour of surgical time, the risk of developing overall complications increases by 16%. These findings suggest that reducing operative time through co-surgeon approaches, consistency in surgical teams, and counseling patients with more risk factors toward delayed reconstructions may mitigate complications. CLINICAL QUESTION/LEVEL OF EVIDENCE Risk, III.
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Affiliation(s)
- Shannon S Wu
- From the Cleveland Clinic Lerner College of Medicine of Case Western Reserve University
| | - Charles Raymer
- Department of Plastic Surgery, Cleveland Clinic, Cleveland
| | - August Culbert
- From the Cleveland Clinic Lerner College of Medicine of Case Western Reserve University
| | - Rachel Schafer
- From the Cleveland Clinic Lerner College of Medicine of Case Western Reserve University
| | - Steven Bernard
- Department of Plastic Surgery, Cleveland Clinic, Cleveland
| | - Risal Djohan
- Department of Plastic Surgery, Cleveland Clinic, Cleveland
| | - Graham Schwarz
- Department of Plastic Surgery, Cleveland Clinic, Cleveland
| | - Sarah N Bishop
- Department of Plastic Surgery, Cleveland Clinic, Cleveland
| | - Raffi Gurunian
- Department of Plastic Surgery, Cleveland Clinic, Abu Dhabi
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Brennan C, Katsura C, Whitehouse H, Allouni A, Akali A. Drain-free donor site in Deep Inferior Epigastric Perforator free flap: A single-surgeon experience. J Plast Reconstr Aesthet Surg 2023; 85:59-64. [PMID: 37478651 DOI: 10.1016/j.bjps.2023.01.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 08/09/2022] [Accepted: 01/29/2023] [Indexed: 02/09/2023]
Abstract
Donor-site seroma and wound dehiscence in Deep Inferior Epigastric Perforator (DIEP) free flaps can be problematic. The value of donor-site drains is debated, with alternative closure techniques demonstrating good outcomes. However, no literature exists on patient outcomes in which no drain or dead space reduction technique is used. The senior author of this paper has opted for a drain-free, simple layered closure without adjuncts since 2016. We evaluate the outcomes of this technique against the literature. A single-center, single-surgeon, prospective study of all DIEP flap breast reconstruction between January 2016 and March 2020, whereby the donor site was closed without drains or alternative dead space reduction measures. One hundred and thirty-eight patients with a mean age of 50.72±9.16 (range 26-73) underwent DIEP breast reconstruction (78% unilateral (n = 107), 22% bilateral (n = 31). The incidence of drain-free specific donor-site complications was 9.4%, with wound breakdown being the most common (9/138, 6.5%). However, only one patient required secondary closure. The average length of hospital stay was 4.2±1 days (range 2-9). Abdominal drains may serve as a psychological barrier for patients in expediting discharge and can be painful and cumbersome. This translates into significant cost implications. Evidence suggests that superior outcomes are achieved when dead space-reducing adjuncts rather than drains are used. However, our data suggest that DIEP donor sites can also be safely closed without these adjuncts, which may unnecessarily lengthen procedure time, consume more resources, and increase localized foreign body tissue reactions, without good indication.
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Affiliation(s)
- Christie Brennan
- Department of Plastic and Reconstructive Surgery, Hull University Teaching Hospitals, Hull, United Kingdom.
| | - Chie Katsura
- Department of Plastic and Reconstructive Surgery, Hull University Teaching Hospitals, Hull, United Kingdom
| | - Harry Whitehouse
- Department of Plastic and Reconstructive Surgery, Hull University Teaching Hospitals, Hull, United Kingdom
| | - Ammar Allouni
- Department of Plastic and Reconstructive Surgery, Hull University Teaching Hospitals, Hull, United Kingdom
| | - Augustine Akali
- Department of Plastic and Reconstructive Surgery, Hull University Teaching Hospitals, Hull, United Kingdom
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Kim PJ, Yuan M, Wu J, Gallo L, Uhlman K, Voineskos SH, O’Neill A, Hofer SO. "Spin" in Observational Studies in Deep Inferior Epigastric Perforator Flap Breast Reconstruction: A Systematic Review. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e5095. [PMID: 37351115 PMCID: PMC10284325 DOI: 10.1097/gox.0000000000005095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Accepted: 04/26/2023] [Indexed: 06/24/2023]
Abstract
The deep inferior epigastric artery perforator (DIEP) flap is widely used in autologous breast reconstruction. However, the technique relies heavily on nonrandomized observational research, which has been found to have high risk of bias. "Spin" can be used to inappropriately present study findings to exaggerate benefits or minimize harms. The primary objective was to assess the prevalence of spin in nonrandomized observational studies on DIEP reconstruction. The secondary objectives were to determine the prevalence of each spin category and strategy. Methods MEDLINE and Embase databases were searched from January 1, 2015, to November 15, 2022. Spin was assessed in abstracts and full-texts of included studies according to criteria proposed by Lazarus et al. Results There were 77 studies included for review. The overall prevalence of spin was 87.0%. Studies used a median of two spin strategies (interquartile range: 1-3). The most common strategies identified were causal language or claims (n = 41/77, 53.2%), inadequate extrapolation to larger population, intervention, or outcome (n = 27/77, 35.1%), inadequate implication for clinical practice (n = 25/77, 32.5%), use of linguistic spin (n = 22/77, 28.6%), and no consideration of the limitations (n = 21/77, 27.3%). There were no significant associations between selected study characteristics and the presence of spin. Conclusions The prevalence of spin is high in nonrandomized observational studies on DIEP reconstruction. Causal language or claims are the most common strategy. Investigators, reviewers, and readers should familiarize themselves with spin strategies to avoid misinterpretation of research in DIEP reconstruction.
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Affiliation(s)
- Patrick J. Kim
- From the Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Morgan Yuan
- Division of Plastic, Reconstructive and Aesthetic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Jeremy Wu
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Lucas Gallo
- Division of Plastic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Kathryn Uhlman
- Division of Plastic, Reconstructive and Aesthetic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Sophocles H. Voineskos
- Division of Plastic, Reconstructive and Aesthetic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Anne O’Neill
- Division of Plastic, Reconstructive and Aesthetic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Stefan O.P. Hofer
- Division of Plastic, Reconstructive and Aesthetic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
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Prophylactic Antibiotics for Deep Inferior Epigastric Perforator Flap Breast Reconstruction: A Comparison between Three Different Duration Approaches. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e4833. [PMID: 36845865 PMCID: PMC9946379 DOI: 10.1097/gox.0000000000004833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Accepted: 01/11/2023] [Indexed: 02/24/2023]
Abstract
There is no consensus on the duration of prophylactic antibiotic use for autologous breast reconstruction after mastectomy. We attempted to standardize the use of prophylactic antibiotics after mastectomy using a deep inferior epigastric perforator flap for the breast reconstruction procedure. Methods This retrospective case series included 108 patients who underwent immediate breast reconstruction with a deep inferior epigastric perforator flap at the Ditmanson Medical Foundation Chia-Yi Christian Hospital between 2012 and 2019. Patients were divided into three groups based on the duration of prophylactic antibiotic administration (1, 3, and >7 days) for patients with drains. Data were analyzed between January and April 2021. Results The prevalence of surgical site infection in the breast was 0.93% (1/108), and in the abdomen it was 0%. The patient groups did not differ by age, body mass index, smoking status, or neoadjuvant chemotherapy. Only one patient experienced surgical site infection in the breast after half-deep necrosis of the inferior epigastric perforator flap. There were no significant differences in surgical site infection based on the duration of prophylactic antibiotic use. The operation time, methods of breast surgery, volume of fluid drainage in the first 3 days of the abdominal and breast drains, and day of removal of the abdominal and breast drains did not affect surgical site infection. Conclusion Based on these data, we do not recommend extending prophylactic antibiotics beyond 24 hours in deep inferior epigastric perforator reconstruction.
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Joo A, Giatsidis G. "In Free Flap Autologous Breast Reconstruction Frailty Is a More Accurate Predictor of Postoperative Complications than Age, Body Mass Index, or ASA class: A Retrospective Cohort Analysis on the ACS-NSQIP Database.". Plast Reconstr Surg 2022; 150:82S-94S. [PMID: 35943961 DOI: 10.1097/prs.0000000000009531] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Free flap autologous breast reconstruction (f-ABR) improves quality of life in cancer survivors but has a 5-47% higher postoperative complication (PCs) rate in vulnerable patients, such as those with obesity or the elderly. Given the high (respectively: 43% and 16%) and rising prevalence of these conditions, operative risk prediction is critical to guide targeted care. Age, BMI, and ASA class have shown inaccuracies as predictive factors of PCs in f-ABR. Since frailty, a measure of vulnerability, was reported to be a reliable predictor of PCs in multiple other surgical fields, we hypothesized that it would be an accurate predictor of PCs also in f-ABR. METHODS Patients undergoing f-ABR (CPT: 19364) were identified using the ACS-NSQIP (American College of Surgeons-National Surgical Quality Improvement Program) database (01/2010-12/2018). Frailty was calculated using the validated modified Frailty Index (mFI). Rates of wound complications, bleeding episodes, readmissions, returns to operating room (ROR), and DVTs were compared across mFI score, BMI, age, and ASA class. RESULTS mFI ≥ 2 was associated with 22.22% (p <0.001) wound complications; 15.79% (p <0.001) bleeding episodes; 8.20% (p <0.001) readmissions; 17.19% (p <0.001) ROR; and 1.81% (p <0.05) DVTs. Higher BMI, age, and ASA class did not significantly correlate with increased rates in one or more PCs. Only a high mFI was consistently associated with significantly higher odds of complications in all complication types. CONCLUSIONS As a reliable and accurate predictor of PCs in f-ABR, frailty could be used preoperatively to counsel patients and guide surgical care.
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Affiliation(s)
- Alex Joo
- Division of Plastic Surgery, University of Massachusetts Medical School
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9
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Yuan M, Wu J, Lee J, Cao D, Huynh MNQ, Gallo L, Neill ACO, Hofer SO. The Risk of Bias of Non-Randomized Observational Studies in Deep Inferior Epigastric Perforator Flap Breast Reconstruction: A Systematic Review using ROBINS-I. J Plast Reconstr Aesthet Surg 2022; 75:4096-4105. [DOI: 10.1016/j.bjps.2022.06.093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 06/07/2022] [Accepted: 06/21/2022] [Indexed: 10/31/2022]
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Pruimboom T, Lindelauf AAMA, Felli E, Sawor JH, Deliaert AEK, van der Hulst RRWJ, Al-Taher M, Diana M, Schols RM. Perioperative Hyperspectral Imaging to Assess Mastectomy Skin Flap and DIEP Flap Perfusion in Immediate Autologous Breast Reconstruction: A Pilot Study. Diagnostics (Basel) 2022; 12:diagnostics12010184. [PMID: 35054352 PMCID: PMC8774932 DOI: 10.3390/diagnostics12010184] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 01/03/2022] [Accepted: 01/10/2022] [Indexed: 12/10/2022] Open
Abstract
Mastectomy skin flap necrosis (MSFN) and partial DIEP (deep inferior epigastric artery perforator) flap loss represent two frequently reported complications in immediate autologous breast reconstruction. These complications could be prevented when areas of insufficient tissue perfusion are detected intraoperatively. Hyperspectral imaging (HSI) is a relatively novel, non-invasive imaging technique, which could be used to objectively assess tissue perfusion through analysis of tissue oxygenation patterns (StO2%), near-infrared (NIR%), tissue hemoglobin (THI%), and tissue water (TWI%) perfusion indices. This prospective clinical pilot study aimed to evaluate the efficacy of HSI for tissue perfusion assessment and to identify a cut-off value for flap necrosis. Ten patients with a mean age of 55.4 years underwent immediate unilateral autologous breast reconstruction. Prior, during and up to 72 h after surgery, a total of 19 hyperspectral images per patient were acquired. MSFN was observed in 3 out of 10 patients. No DIEP flap necrosis was observed. In all MSFN cases, an increased THI% and decreased StO2%, NIR%, and TWI% were observed when compared to the vital group. StO2% was found to be the most sensitive parameter to detect MSFN with a statistically significant lower mean StO2% (51% in the vital group versus 32% in the necrosis group, p < 0.0001) and a cut-off value of 36.29% for flap necrosis. HSI has the potential to accurately assess mastectomy skin flap perfusion and discriminate between vital and necrotic skin flap during the early postoperative period prior to clinical observation. Although the results should be confirmed in future studies, including DIEP flap necrosis specifically, these findings suggest that HSI can aid clinicians in postoperative mastectomy skin flap and DIEP flap monitoring.
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Affiliation(s)
- Tim Pruimboom
- Department of Plastic, Reconstructive and Hand Surgery, Maastricht University Medical Center, 6200 MD Maastricht, The Netherlands;
- Correspondence: (T.P.); (R.M.S.); Tel.: +31-(0)43-3877481 (T.P. & R.M.S.)
| | - Anouk A. M. A. Lindelauf
- Department of Cardiothoracic Surgery, Maastricht University Medical Center, 6229 HX Maastricht, The Netherlands;
| | - Eric Felli
- Department of Visceral Surgery and Medicine, University of Bern, 3010 Bern, Switzerland;
- Department of Biomedical Research, Hepatology, University of Bern, 3012 Bern, Switzerland
| | - John H. Sawor
- Department of Plastic, Reconstructive, and Hand Surgery, VieCuri Medical Center, 5912 BL Venlo, The Netherlands; (J.H.S.); (A.E.K.D.)
| | - An E. K. Deliaert
- Department of Plastic, Reconstructive, and Hand Surgery, VieCuri Medical Center, 5912 BL Venlo, The Netherlands; (J.H.S.); (A.E.K.D.)
| | - René R. W. J. van der Hulst
- Department of Plastic, Reconstructive and Hand Surgery, Maastricht University Medical Center, 6200 MD Maastricht, The Netherlands;
| | - Mahdi Al-Taher
- Department of Surgery, Maastricht University Medical Center, 6229 HX Maastricht, The Netherlands;
- Research Institute Against Digestive Cancer (IRCAD), 67000 Strasbourg, France;
| | - Michele Diana
- Research Institute Against Digestive Cancer (IRCAD), 67000 Strasbourg, France;
- Department of General, Digestive and Endocrine Surgery, University Hospital of Strasbourg, 67200 Strasbourg, France
- ICube Lab, Photonics for Health, University of Strasbourg, 67400 Strasbourg, France
| | - Rutger M. Schols
- Department of Plastic, Reconstructive and Hand Surgery, Maastricht University Medical Center, 6200 MD Maastricht, The Netherlands;
- Correspondence: (T.P.); (R.M.S.); Tel.: +31-(0)43-3877481 (T.P. & R.M.S.)
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11
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Heller DR, Zhuo H, Zhang Y, Parikh N, Fusi S, Alperovich M, Lannin DR, Higgins SA, Avraham T, Killelea BK. Surgical Outcomes of Mastectomy with Immediate Autologous Reconstruction Followed by Radiation. Ann Surg Oncol 2020; 28:2169-2179. [PMID: 32974699 DOI: 10.1245/s10434-020-09122-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Accepted: 07/21/2020] [Indexed: 12/25/2022]
Abstract
INTRODUCTION Timing of autologous reconstruction relative to postmastectomy radiation therapy (PMRT) is debated. Benefits of immediate reconstruction must be weighed against a possibly heightened risk of complications from flap irradiation. We reviewed flap outcomes after single operation plus PMRT in a large institutional cohort. METHODS Medical records were reviewed for women who underwent simultaneous mastectomy-autologous reconstruction with PMRT from 2007 to 2016. Primary endpoints were rates and types of radiation-related flap complications and reoperations, whose predictors were assessed by multivariable analysis. A p value < 0.10 was deemed significant to avoid type II error. Non-parametric logistic regression generated a model of PMRT timing associated with probabilities of complications and reoperations. RESULTS One-hundred and thirty women underwent 208 mastectomy reconstruction operations, with a median follow up of 35.1 months (interquartile range 23.6-56.5). Forty-seven (36.2%) women experienced radiation-related complications, commonly fat necrosis (44.1%) and chest wall asymmetry (28.8%). Complications were higher among women who received PMRT < 3 months after surgery (46.8% for < 3 months vs. 29.3% for ≥ 3 months; p = 0.06), most of whom received neoadjuvant chemotherapy, and among women treated with internal mammary nodal (IMN) radiation (65.2% vs. 26.4%; p < 0.01); IMN radiation remained strongly associated in multivariable analysis (odds ratio [OR] 5.24; p < 0.01). Thirty-two (24.6%) women underwent 70 reoperations, commonly fat grafting (51.9%) and fat necrosis excision (17.1%). Reoperations were higher among women who received PMRT < 3 months after surgery (48.9 for < 3 months vs. 36.6 for ≥ 3 months; p = 0.19), which was significantly associated in multivariable analysis (OR 0.42; p = 0.08 for ≥ 3 months). The probabilities of complications and reoperations were lowest when PMRT was administered ≥ 3 months after surgery. CONCLUSIONS Among a large institutional cohort, immediate autologous reconstruction was associated with similar rates of adverse flap outcomes as historically reported alternatively sequenced protocols. IMN radiation increased risk, while PMRT ≥ 3 months after surgery decreased risk. Additional studies are needed to elaborate the impact of IMN radiation and early PMRT in immediate versus delayed autologous reconstruction.
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Affiliation(s)
- Danielle R Heller
- Department of Surgery, Yale University School of Medicine, New Haven, CT, USA
| | - Haoran Zhuo
- School of Public Health, Yale University School of Medicine, New Haven, CT, USA
| | - Yawei Zhang
- School of Public Health, Yale University School of Medicine, New Haven, CT, USA
| | - Nisha Parikh
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, CT, USA
| | - Stefano Fusi
- Department of Surgery, Yale University School of Medicine, New Haven, CT, USA
| | - Michael Alperovich
- Division of Plastic and Reconstructive Surgery, Yale University School of Medicine, New Haven, CT, USA
| | - Donald R Lannin
- The Breast Center, Department of Surgery, Yale University School of Medicine, New Haven, CT, USA
| | - Susan A Higgins
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, CT, USA
| | - Tomer Avraham
- Division of Plastic and Reconstructive Surgery, Yale University School of Medicine, New Haven, CT, USA
| | - Brigid K Killelea
- The Breast Center, Department of Surgery, Yale University School of Medicine, New Haven, CT, USA.
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Cao Z, Cao J, Pang X, Du W, Wu P. A comparative study for the rate of adverse outcomes in unilateral and bilateral abdominal flap breast reconstruction: A meta-analysis. Medicine (Baltimore) 2020; 99:e22096. [PMID: 32925752 PMCID: PMC7489626 DOI: 10.1097/md.0000000000022096] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
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.
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Affiliation(s)
- Zheming Cao
- Department of Orthopedics, Xiangya Hospital of Central South University
| | - Jiri Cao
- Xiangya Nursing School of Central South University, Changsha, China
| | - Xiaoyang Pang
- Department of Orthopedics, Xiangya Hospital of Central South University
| | - Wei Du
- Department of Orthopedics, Xiangya Hospital of Central South University
| | - Panfeng Wu
- Department of Orthopedics, Xiangya Hospital of Central South University
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Bijkerk E, van der Hulst RRWJ, Lataster A, Tuinder SMH. The Sc-GAP makeover flap: eliminating the need for position changes in gluteal flap breast reconstruction. EUROPEAN JOURNAL OF PLASTIC SURGERY 2020. [DOI: 10.1007/s00238-020-01659-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Abstract
Background
The gluteal region is one of the many alternative donor sites for autologous breast reconstruction. However, the harvest of the gluteal flap is rather difficult, and the major drawback of gluteal flaps has been the need for position changes for flap harvest and inset. A new approach of a gluteal flap is introduced, based on the septocutaneous perforators of the superior gluteal artery: the septocutaneous gluteal artery perforator (Sc-GAP) makeover flap.
Methods
A prospective study was performed in Maastricht University Medical Center between January 2018 and December 2019. Patients who underwent a Sc-GAP makeover flap breast reconstruction in the Maastricht University Medical Center and have had preoperative magnetic resonance angiography (MRA) of the abdomen between January 2018 and June 2019 were included.
Results
Nine patients underwent breast reconstruction with thirteen Sc-GAP makeover flaps, of which nine flaps were innervated. Indications were the abdomen not being available as a donor site (n = 4) or the flank region was preferred as a donor site by the patient (n = 5). The total operative time was 430 min on average (range 311–683). Mean flap weight was 638 g (range 370–1004) and the mean ischemia time was 53 ± 9.96 min. Coupler size used was 2.0–2.5 mm. All flaps survived.
Conclusion
The Sc-GAP makeover flap overcomes the disadvantages of the conventional gluteal flaps, especially by eliminating the need for position changes during the reconstruction procedure. It is a reliable flap that provides sufficient volume and good esthetic outcomes.
Level of evidence: Level IV, therapeutic study.
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Hillberg NS, Beugels J, van Kuijk SMJ, van der Hulst RRJW, Tuinder SMH. Increase of major complications with a longer ischemia time in breast reconstruction with a free deep inferior epigastric perforator (DIEP) flap. EUROPEAN JOURNAL OF PLASTIC SURGERY 2020. [DOI: 10.1007/s00238-019-01584-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Abstract
Background
The deep inferior epigastric artery perforator (DIEP) flap is one of the most used free flaps for postmastectomy breast reconstruction. Prolonged ischemia can result in (partial) flap loss. The aim of this study was to evaluate the association between ischemia time and postoperative complications of DIEP flap breast reconstruction.
Methods
A retrospective study of all patients who received a breast reconstructionwith aDIEP flap atMaastricht University Medical Center in theNetherlands, between January 2010 and June 2017 (n = 677). The flaps were divided into two groups: flaps with an ischemia time less than 60 min and those with 60 min or more. Recipient site complications, in particular major complications equal to re-exploration, and partial or total flap loss were the primary outcome measures.
Results
In 23.9% of the 677 included DIEP flaps, the ischemia time was 60 min or longer. Within this group, a complication of the recipient site occurred in 30.9% of the flaps. A major complication occurred in 17.3% of the flaps with 60 min or more ischemia time.With regard to the flaps with less than 60-min ischemia time, a complication occurred in 22.1% of the cases of which 8.9%would be considered amajor complication. A significant association was found between ischemia time and major complications on univariate (p value = 0.003) and multivariate analyses (p value = 0.016).
Conclusions
This study demonstrates that an ischemia time less than 60 min is associated with a significantly lower risk of major recipient site complications compared to an ischemia time of 60 min or more.
Level of evidence: Level III, therapeutic, risk/prognostic study.
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15
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Incidence of Complications in Delayed Abdominal-Based Flap Breast Reconstruction Using a Drainless Recipient Site: A Case Series. Ann Plast Surg 2020; 85:S37-S40. [PMID: 32205496 DOI: 10.1097/sap.0000000000002328] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Seroma is a common complication after breast surgery such as mastectomy and immediate reconstruction. However, there is a lack of evidence for the utility of drains in the recipient site in delayed autologous breast reconstruction. We reviewed our experience with delayed abdominal-based flap breast reconstruction with a drainless recipient site. METHODS A single-surgeon retrospective case review was performed for delayed abdominal-based flap breast reconstruction using drainless recipient sites from May 2018 to June 2019. Primary outcomes were recipient-site complications. RESULTS Thirty-one delayed abdominal-based flap breast reconstructions that did not use drains in the recipient site were identified in 22 patients. Mean age was 52.8 years (SD, 9.7 years). Mean body mass index was 30.1 kg/m (interquartile range [IQR], 28.2-35.0 kg/m). Common comorbidities were obesity (45.4%), prior tobacco use (31.8%), and diabetes (10.0%). Median time to abdominal-based flap reconstruction was 27.5 months (IQR, 9.9-105.2 months). There were 22 muscle-sparing transverse rectus abdominis musculocutaneous flaps and 9 deep inferior epigastric artery perforator flaps performed. Ten patients (45.4%) underwent bilateral reconstruction. Mean operative time was 302 minutes (SD, 85 minutes). Flap take back occurred in 1 case (3.2%). Mean length of stay was 4 days (SD, 0.8 days). Recipient-site complications were healing complications (32.3%), seroma (3.2%), hematoma (3.2%), and fat necrosis (19.4%). Median follow-up was 4.2 months (IQR, 2.5-11.5). CONCLUSIONS In this case series, our data indicate that delayed autologous reconstruction without drain placement at the recipient site has been proven to be safe and successful and did not increase the rate of seroma or other complications. Adopting a drainless approach may also improve patient comfort and satisfaction.
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The influence of neoadjuvant chemotherapy on complications of immediate DIEP flap breast reconstructions. Breast Cancer Res Treat 2019; 176:367-375. [PMID: 31030303 PMCID: PMC6555777 DOI: 10.1007/s10549-019-05241-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Accepted: 04/15/2019] [Indexed: 10/26/2022]
Abstract
PURPOSE The impact of neoadjuvant chemotherapy on the surgical outcomes of immediate breast reconstruction remains controversial. The aim of this study was to analyze the incidence of complications of immediate deep inferior epigastric artery perforator (DIEP) flap breast reconstructions in patients who received neoadjuvant chemotherapy compared to patients without neoadjuvant chemotherapy prior to surgery. METHODS A multicenter, retrospective cohort study was conducted of all patients who underwent immediate DIEP flap breast reconstruction between January 2010 and June 2017. Patients were divided in two groups as breast reconstructions with or without neoadjuvant chemotherapy, respectively. The primary outcome was the incidence of postoperative flap re-explorations, recipient-site complications and donor-site complications. RESULTS In total 432 immediate DIEP flap breast reconstructions in 326 patients were included. Forty-eight patients (n = 67 flaps) received neoadjuvant chemotherapy prior to immediate breast reconstruction and 278 patients (n = 365 flaps) did not. No statistically significant differences for any major (4.5% vs. 10.4%; p = 0.175) or minor (16.4% vs. 24.7%; p = 0.191) recipient-site complication were observed. Donor-site complications were recorded in 9 (18.8%) and 62 (22.2%) patients, respectively (p = 0.587). There was no difference in need for flap re-exploration between groups (3.0% vs. 8.5%; p = 0.139). Correction for potential confounding variables did not result in significant differences. CONCLUSIONS This study demonstrated similar complication rates for patients with and without neoadjuvant chemotherapy prior to immediate breast reconstruction, indicating that it is safe to perform an immediate DIEP flap breast reconstruction after neoadjuvant chemotherapy.
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The Stacked Hemiabdominal Extended Perforator Flap for Autologous Breast Reconstruction. Plast Reconstr Surg 2019; 142:1424-1434. [PMID: 30204680 DOI: 10.1097/prs.0000000000005058] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Options for bilateral autologous breast reconstruction in thin women are limited. The aim of this study was to introduce a novel approach to increase abdominal flap volume with the stacked hemiabdominal extended perforator (SHAEP) flap. The authors describe the surgical technique and analyze their results. METHODS A retrospective study was conducted of all SHAEP flap breast reconstructions performed since February of 2014. Patient demographics, operative details, complications, and flap reexplorations were recorded. The bipedicled hemiabdominal flap was designed as a combination of the deep inferior epigastric artery perforator (DIEP) and a second, more lateral pedicle: the deep or superficial circumflex iliac perforator vessels, the superficial inferior epigastric artery, or a lumbar artery or intercostal perforator. RESULTS A total of 90 SHAEP flap breast reconstructions were performed in 49 consecutive patients. Median operative time was 500 minutes (range, 405 to 797 minutes). Median hemiabdominal flap weight that was used for reconstruction was 598 g (range, 160 to 1389 g). No total flap losses were recorded. Recipient-site complications included partial flap loss (2.2 percent), hematoma (3.3 percent), fat necrosis (2.2 percent), and wound problems (4.4 percent). Minor donor-site complications occurred in five patients (10.2 percent). Most flaps were harvested on a combination of the DIEP and deep circumflex iliac artery vessels. CONCLUSIONS This study demonstrated that the SHAEP flap is an excellent option for bilateral autologous breast reconstruction in women who require significant breast volume but have insufficient abdominal tissue for a bilateral DIEP flap. The bipedicled SHAEP flap allows for enhanced flap perfusion, increased volume, and abdominal contour improvement using a single abdominal donor site. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.
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18
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Cho JM, Lee HC, Lee TJ, Kim EK. Unilateral pedicled transverse rectus abdominis musculocutaneous flap and unilateral free deep inferior epigastric artery perforator flap as a surgical alternative in bilateral autologous breast reconstruction. ARCHIVES OF AESTHETIC PLASTIC SURGERY 2019. [DOI: 10.14730/aaps.2019.25.1.9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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19
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Wain RAJ, Gaskell NJ, Fsadni AM, Francis J, Whitty JPM. Finite Element Predictions of Sutured and Coupled Microarterial Anastomoses. ADVANCED BIOMEDICAL ENGINEERING 2019. [DOI: 10.14326/abe.8.63] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Richard AJ Wain
- John Tyndall Institute, School of Engineering, University of Central Lancashire
- School of Medicine and Dentistry, University of Central Lancashire
- Department of Plastic & Reconstructive Surgery, Royal Preston Hospital, Lancashire Teaching Hospitals NHS Foundation Trust
| | - Nicolas J Gaskell
- John Tyndall Institute, School of Engineering, University of Central Lancashire
| | - Andrew M Fsadni
- John Tyndall Institute, School of Engineering, University of Central Lancashire
| | - Jonathan Francis
- John Tyndall Institute, School of Engineering, University of Central Lancashire
| | - Justin PM Whitty
- John Tyndall Institute, School of Engineering, University of Central Lancashire
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20
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Thacoor A, Kanapathy M, Torres-Grau J, Chana J. Deep inferior epigastric perforator (DIEP) flap: Impact of drain free donor abdominal site on long term patient outcomes and duration of inpatient stay. J Plast Reconstr Aesthet Surg 2018; 71:1103-1107. [DOI: 10.1016/j.bjps.2018.04.019] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Revised: 03/21/2018] [Accepted: 04/29/2018] [Indexed: 10/16/2022]
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21
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The Lateral Thigh Perforator Flap for Autologous Breast Reconstruction: A Prospective Analysis of 138 Flaps. Plast Reconstr Surg 2018; 141:257-268. [PMID: 29019861 DOI: 10.1097/prs.0000000000004072] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The septocutaneous tensor fasciae latae or lateral thigh perforator flap was previously introduced by the authors' group as an alternative flap for autologous breast reconstruction when the abdomen is not suitable as a donor site. The authors analyzed their experience with the lateral thigh perforator flap and present the surgical refinements that were introduced. METHODS A prospective study was conducted of all lateral thigh perforator flap breast reconstructions performed since September of 2012. Patient demographics, operative details, complications, and flap reexplorations were recorded. Preoperative imaging with magnetic resonance angiography was performed in all patients. Surgical refinements introduced during this study included limitation of the flap width and the use of quilting sutures at the donor site. RESULTS A total of 138 lateral thigh perforator flap breast reconstructions were performed in 86 consecutive patients. Median operative times were 277 minutes (range, 196 to 561 minutes) for unilateral procedures and 451 minutes (range, 335 to 710 minutes) for bilateral. Median flap weight was 348 g (range, 175 to 814 g). Two total flap losses (1.4 percent) were recorded, and 11 flaps (8.0 percent) required reexploration, which resulted in viable flaps. The incidence of donor-site complications was reduced significantly after the surgical refinements were introduced. Wound problems decreased from 40.0 percent to 6.3 percent, seroma decreased from 25.0 percent to 9.5 percent, and infection decreased from 27.5 percent to 9.5 percent. CONCLUSIONS The lateral thigh perforator flap is an excellent option for autologous breast reconstruction, with minimal recipient-site complications. The surgical refinements resulted in a significant reduction of donor-site complications. Therefore, the lateral thigh perforator flap is currently the authors' second choice after the deep inferior epigastric artery perforator flap. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.
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Wain RAJ, Smith DJ, Hammond DR, Whitty JPM. Influence of microvascular sutures on shear strain rate in realistic pulsatile flow. Microvasc Res 2018. [PMID: 29522755 DOI: 10.1016/j.mvr.2018.03.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Arterial thrombus formation is directly related to the mechanical shear experienced by platelets within flow. High shear strain rates (SSRs) and large shear gradients cause platelet activation, aggregation and production of thrombus. This study, for the first time, investigates the influence of pulsatile flow on local haemodynamics within sutured microarterial anastomoses. We measured physiological arterial waveform velocities experimentally using Doppler ultrasound velocimetry, and a representative example was applied to a realistic sutured microarterial geometry. Computational geometries were created using measurements taken from sutured chicken femoral arteries. Arterial SSRs were predicted using computational fluid dynamics (CFD) software, to indicate the potential for platelet activation, deposition and thrombus formation. Predictions of steady and sinusoidal inputs were compared to analyse whether the addition of physiological pulse characteristics affects local intravascular flow characteristics. Simulations were designed to evaluate flow in pristine and hand-sutured microarterial anastomoses, each with a steady-state and sinusoidal pulse component. The presence of sutures increased SSRmax in the anastomotic region by factors of 2.1 and 2.3 in steady-state and pulsatile flows respectively, when compared to a pristine vessel. SSR values seen in these simulations are analogous to the presence of moderate arterial stenosis. Steady-state simulations, driven by a constant inflow velocity equal to the peak systolic velocity (PSV) of the measured pulsatile flow, underestimated SSRs by ∼ 9% in pristine, and ∼ 19% in sutured vessels compared with a realistic pulse. Sinusoidal flows, with equivalent frequency and amplitude to a measured arterial waveform, represent a slight improvement on steady-state simulations, but still SSRs are underestimated by 1-2%. We recommend using a measured arterial waveform, of the form presented here, for simulating pulsatile flows in vessels of this nature. Under realistic pulsatile flow, shear gradients across microvascular sutures are high, of the order ∼ 7.9 × 106 m-1 s-1, which may also be associated with activation of platelets and formation of aggregates.
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Affiliation(s)
- R A J Wain
- School of Mathematics, University of Birmingham, B15 2TT, UK; Institute of Translational Medicine, University of Birmingham, B15 2TT, UK; School of Medicine and Dentistry, University of Central Lancashire, Preston PR1 2HE, UK; Computational Mechanics Research Group, School of Engineering, University of Central Lancashire, Preston PR1 2HE, UK.
| | - D J Smith
- School of Mathematics, University of Birmingham, B15 2TT, UK; Institute for Metabolism and Systems Research, University of Birmingham, B15 2TT, UK
| | - D R Hammond
- School of Medicine and Dentistry, University of Central Lancashire, Preston PR1 2HE, UK
| | - J P M Whitty
- Computational Mechanics Research Group, School of Engineering, University of Central Lancashire, Preston PR1 2HE, UK
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Beugels J, Bod L, van Kuijk SMJ, Qiu SS, Tuinder SMH, Heuts EM, Piatkowski A, van der Hulst RRWJ. Complications following immediate compared to delayed deep inferior epigastric artery perforator flap breast reconstructions. Breast Cancer Res Treat 2018; 169:349-357. [PMID: 29399731 PMCID: PMC5945748 DOI: 10.1007/s10549-018-4695-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Accepted: 01/24/2018] [Indexed: 11/26/2022]
Abstract
Purpose As more breast cancer patients opt for immediate breast reconstruction, the incidence of complications should be evaluated. The aim of this study was to analyze the recipient-site complications and flap re-explorations of immediate compared to delayed deep inferior epigastric artery perforator (DIEP) flap breast reconstructions. Methods For this multicenter retrospective cohort study, the medical records of all patients who underwent DIEP flap breast reconstruction in three hospitals in the Netherlands between January 2010 and June 2017 were reviewed. Patient demographics, risk factors, timing of reconstruction, recipient-site complications, and flap re-explorations were recorded. Results A total of 910 DIEP flap breast reconstructions (n = 397 immediate and n = 513 delayed reconstructions) in 737 patients were included. There were no significant differences in major complications or flap re-explorations between immediate and delayed reconstructions. The total flap failure rate was 1.5 and 2.5% in the immediate and delayed group, respectively. Significantly more hematomas (OR 2.91; 95% CI 1.59–5.30; p = 0.001) and seromas (OR 3.60; 95% CI 1.14–11.4; p = 0.029) occurred in immediate reconstructions, whereas wound problems were more frequently observed in delayed reconstructions (OR 1.99; 95% CI 1.27–3.11; p = 0.003). Correction for potential confounders still showed significant differences for hematoma and seroma, but no longer for wound problems (p = 0.052). Conclusions This study demonstrated similar incidences of major recipient-site complications and flap re-explorations between immediate and delayed DIEP flap breast reconstructions. However, hematoma and seroma occurred significantly more often in immediate reconstructions, while wound problems were more frequently observed in delayed reconstructions. Electronic supplementary material The online version of this article (10.1007/s10549-018-4695-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- J Beugels
- Department of Plastic, Reconstructive and Hand Surgery, Maastricht University Medical Centre, P.O. Box 5800, 6202 AZ, Maastricht, The Netherlands.
- GROW - School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, The Netherlands.
| | - L Bod
- Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - S M J van Kuijk
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Center, Maastricht, The Netherlands
| | - S S Qiu
- Department of Plastic, Reconstructive and Hand Surgery, Maastricht University Medical Centre, P.O. Box 5800, 6202 AZ, Maastricht, The Netherlands
| | - S M H Tuinder
- Department of Plastic, Reconstructive and Hand Surgery, Maastricht University Medical Centre, P.O. Box 5800, 6202 AZ, Maastricht, The Netherlands
| | - E M Heuts
- Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - A Piatkowski
- Department of Plastic, Reconstructive and Hand Surgery, Maastricht University Medical Centre, P.O. Box 5800, 6202 AZ, Maastricht, The Netherlands
- Department of Plastic, Reconstructive and Hand Surgery, VieCuri Medical Center, Venlo, The Netherlands
| | - R R W J van der Hulst
- Department of Plastic, Reconstructive and Hand Surgery, Maastricht University Medical Centre, P.O. Box 5800, 6202 AZ, Maastricht, The Netherlands
- Department of Plastic, Reconstructive and Hand Surgery, VieCuri Medical Center, Venlo, The Netherlands
- Department of Plastic, Reconstructive and Hand Surgery, Zuyderland Medical Center, Sittard-Geleen, The Netherlands
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Bota O, Spindler N, Sauber J, Aydogan E, Langer S. Double-Pedicled Free Deep Inferior Epigastric Perforator Flap for the Coverage of Thigh Soft-Tissue Defect. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2017; 5:e1372. [PMID: 28894652 PMCID: PMC5585425 DOI: 10.1097/gox.0000000000001372] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Accepted: 04/21/2017] [Indexed: 12/01/2022]
Abstract
Soft-tissue defects caused by radiation injury are a challenging task for the reconstructive surgeon, due to the extent of the soft-tissue damage and the associated injuries of the local blood vessels and bone tissue. We present the application of the versatile deep inferior epigastric perforator (DIEP) flap for the coverage of an extended lateral thigh soft-tissue defect after the surgical resection of an undifferentiated pleomorphic high-grade sarcoma, neoadjuvant chemotherapy, and adjuvant chemo- and radiotherapy. A double-pedicled free DIEP flap (756 cm2) was harvested and anastomosed to the transverse branch of the lateral femoral circumflex artery and a lateral branch of the popliteal artery (P1). The flap survived completely without serious complications, and the patient was able to walk with crutches 3 months postoperatively. This is the first case report of a free bipedicled DIEP flap for the coverage of a thigh defect in a male patient.
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Affiliation(s)
- Olimpiu Bota
- Department for Plastic, Aesthetic and special Handsurgery, University Clinic Leipzig, Germany
| | - Nick Spindler
- Department for Plastic, Aesthetic and special Handsurgery, University Clinic Leipzig, Germany
| | - Jeannine Sauber
- Department for Plastic, Aesthetic and special Handsurgery, University Clinic Leipzig, Germany
| | - Emrah Aydogan
- Department for Plastic, Aesthetic and special Handsurgery, University Clinic Leipzig, Germany
| | - Stefan Langer
- Department for Plastic, Aesthetic and special Handsurgery, University Clinic Leipzig, Germany
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Schaverien MV, Butler CE. Complications in DIEP Flap Breast Reconstruction After Mastectomy for Breast Cancer: A Prospective Cohort Study Comparing Unilateral and Bilateral Reconstructions. Ann Surg Oncol 2017; 24:1451-1453. [DOI: 10.1245/s10434-017-5809-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/29/2023]
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Wade RG, Razzano S, Sassoon EM, Haywood RM, Ali RS, Figus A. Complications in DIEP Flap Breast Reconstruction After Mastectomy for Breast Cancer: A Prospective Cohort Study Comparing Unilateral Versus Bilateral Reconstructions. Ann Surg Oncol 2017; 24:1465-1474. [DOI: 10.1245/s10434-017-5807-5] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2016] [Indexed: 01/12/2023]
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