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Yu Y, Liu H, Xu L, Hu P, Cui N, Long J, Wu X, Long D, Zhou Z. Reendothelialization of Acellular Adipose Flaps under Mimetic Physiological Dynamic Conditions. Tissue Eng Part A 2024. [PMID: 38562116 DOI: 10.1089/ten.tea.2023.0340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2024] Open
Abstract
The extensive soft-tissue defects resulting from trauma and tumors pose a prevalent challenge in clinical practice, characterized by a high incidence rate. Autologous tissue flap transplantation, considered the gold standard for treatment, is associated with various drawbacks, including the sacrifice of donor sources, postoperative complications, and limitations in surgical techniques, thereby impeding its widespread applicability. The emergence of tissue-engineered skin flaps, notably the acellular adipose flap (AAF), offers potential alternative solutions. However, a critical concern confronting large-scale tissue-engineered skin flaps currently revolves around the reendothelialization of internal vascular networks. In our study, we have developed an AAF utilizing perfusion decellularization, demonstrating excellent physical properties. Cytocompatibility experiments have confirmed its cellular safety, and cell adhesion experiments have revealed spatial specificity in facilitating endothelial cells adhesion within the adipose flap scaffold. Using a novel mimetic physiological fluid shear stress setting, endothelial cells were dynamically inoculated and cultured within the acellular vascular network of the pedicled AAF in our research. Histological and gene expression analyses have shown that the mimetic physiological fluid dynamic model significantly enhanced the reendothelialization of the AAF. This innovative platform of acellular adipose biomaterials combined with hydrodynamics may offer valuable insights for the design and manufacturing of 3D vascularized tissue constructs, which can be applied to the repair of extensive soft-tissue defects.
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Affiliation(s)
- Yaling Yu
- Department of Orthopedic Surgery, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Institute of Microsurgery on Extremities, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Hui Liu
- Department of Orthopedic Surgery, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Ling Xu
- Department of Ophthalmology, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Ping Hu
- Department of Ophthalmology, Hunan University of Chinese Medicine, Changsha, China
| | - Ning Cui
- Department of Ophthalmology, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jinyi Long
- Department of Ophthalmology, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xue Wu
- Department of Ophthalmology, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Da Long
- Department of Ophthalmology, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Zhengbing Zhou
- Department of Orthopedic Surgery, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Mahrhofer M, Russe E, Schoeller T, Wechselberger G, Weitgasser L. Management of donor-site complications after breast reconstruction with the transverse musculocutaneous gracilis flap: Proposal of a treatment algorithm. Microsurgery 2023; 43:537-545. [PMID: 36688611 DOI: 10.1002/micr.31010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2022] [Revised: 11/24/2022] [Accepted: 01/06/2023] [Indexed: 01/24/2023]
Abstract
BACKGROUND The transverse myocutaneous gracilis (TMG) flap is a popular choice for autologous breast reconstruction due to its consistent anatomy and reliability, especially for slim patients. While the incidence of donor-site morbidity is comparable with other free flaps, there is no literature about the management of donor-site complications available. Our study aims to provide an overview of encountered complications, associated risk factors and their management using a standardized algorithmic approach. METHODS A retrospective review of all patients receiving breast reconstruction with a TMG flap at our institution between September 2010 and May 2021 was performed. Demographic data (age, BMI), comorbidities (diabetes, smoking), complication rates (major, minor) and treatment were evaluated. Medical records were screened for reasons and timing of performed reconstructions. Adapted from the Clavien-Dindo classification system, severity of complication was categorized as either class I-II minor or class IIIa-IIIb major. Data on follow-up procedures was collected. A treatment algorithm for the management of commonly occurring donor-site complications was created, based on our long-running institutional experience. RESULTS Two-hundred and twenty-five patients (288 flaps) were included in our retrospective analysis. There were 43 (14.9%) minor and 4 (2.7%) major donor-site complications overall. Minor complications included superficial wound breakdown (26/9%), infection (10 cases, 3.5%) and hematoseroma (7 cases, 2.4%). Hematoseroma (2 cases, 0.7%) and severe wound breakdown (2 cases, 0.7%) needing revision surgery were the most common major complications. Patients with lower BMI (mean 22.9 kg/m2 vs. 24.0 kg/m2 ; p = .047) and active tobacco use (14.1% vs. 6.3%; p = .046; Relative risk = 1.71 95% CI 1.02-2.88) had a higher occurrence of donor-site complications. Age and operating time were not associated with higher complication rates. Four patients (1.4%) received donor-site refinement surgery. CONCLUSION The TMG flap provides a reliable and safe alternative for breast reconstruction and most donor-site complications can be managed conservatively. Our proposed treatment algorithm aids with decision making in the management of donor-site complications.
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Affiliation(s)
- Maximilian Mahrhofer
- Department of Plastic and Reconstructive Surgery, Marienhospital Stuttgart, Teaching Hospital of the Eberhard Karls University Tuebingen, Tuebingen, Germany
| | - Elisabeth Russe
- Department of Plastic and Reconstructive Surgery, Hospital of the Brothers of St. John of God (Barmherzige Brüder), Paracelsus Medical University, Salzburg, Austria
| | - Thomas Schoeller
- Department of Plastic and Reconstructive Surgery, Marienhospital Stuttgart, Teaching Hospital of the Eberhard Karls University Tuebingen, Tuebingen, Germany
| | - Gottfried Wechselberger
- Department of Plastic and Reconstructive Surgery, Hospital of the Brothers of St. John of God (Barmherzige Brüder), Paracelsus Medical University, Salzburg, Austria
| | - Laurenz Weitgasser
- Department of Plastic and Reconstructive Surgery, Marienhospital Stuttgart, Teaching Hospital of the Eberhard Karls University Tuebingen, Tuebingen, Germany
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He X, Wang S, Yu X, Zhou X. Bone marrow mesenchymal stem cells response on collagen/hyaluronan/chondroitin scaffold enriched with gentamicin -loaded gelatin microparticles for skin tissue engineering. J Biomater Appl 2023:8853282231180714. [PMID: 37276487 DOI: 10.1177/08853282231180714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
The repair and functional reconstruction of large skin defects caused by burn remains an intractable clinical problem. Collagen type I (ColI) was extracted from carp scales and confirmed by sodium dodecyl sulfate-polyacrylamide gel electrophoresis ultraviolet adsorption spectra and automatic amino acid analyzer. Then the scaffolds containing the purified ColI, hyaluronic acid (HA) and chondroitin sulfate (CS) were constructed and examined. The results showed that the scaffold (ColI:CS:HA=9:1:1) had larger pore diameter, porosity, water absorption, degradation rate and tensile strength. gentamycin sulphate (GS) - gelatin microspheres (GMSs) were prepared by emulsion cross-linking method. The drug release study of the ColI-CS-HA-GS/GMSs scaffold with antibacterial property showed a prolonged, continuous, and sustained release of GS. The bone marrow mesenchymal stem cells (BMSCs) were extracted from rat and inoculated into the ColI-HA-CS-GS/GMSs scaffold. The results performed that the scaffold could accelerate proliferation of the BMSCs and wound healing.
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Affiliation(s)
- Xiaoliang He
- Hebei University of Science and Technology, Shijiazhuang, China
| | - Shuai Wang
- Hebei University of Science and Technology, Shijiazhuang, China
| | - Xinran Yu
- Hebei University of Science and Technology, Shijiazhuang, China
| | - Xiaohui Zhou
- Hebei University of Science and Technology, Shijiazhuang, China
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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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Ahmed Z, Ioannidi L, Ghali S, Hamilton S, Shtarbanov P, Mosahebi A, Nikkhah D. A Single-center Comparison of Unipedicled and Bipedicled Diep Flap Early Outcomes in 98 Patients. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e5089. [PMID: 37361509 PMCID: PMC10289681 DOI: 10.1097/gox.0000000000005089] [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: 03/08/2023] [Accepted: 05/02/2023] [Indexed: 06/28/2023]
Abstract
The deep inferior epigastric perforator (DIEP) flap is the gold standard for autologous breast reconstruction. One or two pedicles may be used. Our study is the first to compare unipedicled and bipedicled DIEP flaps on donor and recipient site outcomes in the same patient cohort. Methods This is a retrospective cohort study comparing DIEP flap outcomes between 2019 and 2022. Results There were 98 patients, categorized differently for recipient or donor site. The recipient groups were unilateral unipedicled (N = 52), bilateral unipedicled (N = 15), and unilateral bipedicled (N = 31), and donor site groups were unipedicled (N = 52) and bipedicled (N = 46, including bilateral unipedicled and unilateral bipedicled). Bipedicled DIEP flaps had 1.15 times greater odds of donor site complication (95% CI, 0.52-2.55). Adjusting for operative time that was longer in bipedicled DIEP flaps (P < 0.001), odds ratio decreased, and there was a lower probability of donor site complication for bipedicled flaps (OR, 0.84; 95% CI, 0.31-2.29). Odds of recipient area complication was not significantly different between groups. Unilateral unipedicled DIEP flaps had significantly higher rates of revisional elective surgery than unilateral bipedicled DIEP flaps (40.4% versus 12.9%; P = 0.029). Conclusions We demonstrate no significant difference in donor site morbidity between unipedicled and bipedicled DIEP flaps. Bipedicled DIEP flaps do have slightly higher rates of donor site morbidity, which can be partly explained by longer operative times. There is no significant difference in recipient site complications, and bipedicled DIEP flaps can reduce rates of further elective surgery.
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Affiliation(s)
- Zahra Ahmed
- From the Division of Surgery and Interventional Sciences, University College London, London, United Kingdom
| | - Lydia Ioannidi
- Department of Plastic and Reconstructive Surgery, Royal Free London NHS Foundation Trust, London, United Kingdom
| | - Shadi Ghali
- Department of Plastic and Reconstructive Surgery, Royal Free London NHS Foundation Trust, London, United Kingdom
| | - Stephen Hamilton
- Department of Plastic and Reconstructive Surgery, Royal Free London NHS Foundation Trust, London, United Kingdom
| | - Petko Shtarbanov
- Division of Surgery and Interventional Sciences, University College London, London, United Kingdom
| | - Afshin Mosahebi
- Department of Plastic and Reconstructive Surgery, Royal Free London NHS Foundation Trust, London, United Kingdom
- Division of Surgery and Interventional Sciences, University College London, London, United Kingdom
| | - Dariush Nikkhah
- Department of Plastic and Reconstructive Surgery, Royal Free London NHS Foundation Trust, London, United Kingdom
- Division of Surgery and Interventional Sciences, University College London, London, United Kingdom
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Amakiri UO, Doo FX, Kuruvilla A, Ibelli TJ, Jesús GHD, Kagen A, Henderson PW. Periumbilical Anatomy of Scarpa's Fascia: Rationale Behind a "Modified Scarpa's" Abdominal Closure Technique. Ann Plast Surg 2023; 90:S252-S255. [PMID: 36752536 DOI: 10.1097/sap.0000000000003404] [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: 02/09/2023]
Abstract
BACKGROUND Intraoperative observation of Scarpa's fascia (SF) has suggested attenuation in the periumbilical region. This study's purpose was to objectively evaluate SF anatomy in the periumbilical region and assess clinical outcomes of a novel, modified SF closure technique of transverse abdominal wall incisions that only reapproximates SF where it is definitively present. METHODS Women were identified who had undergone abdominal magnetic resonance (MR) angiography before their abdominal-based autologous breast reconstruction that used the modified SF closure technique. Statistical analysis of SF presentation on the MR images was performed. Intraoperative measurements from dissected panniculectomy specimens were used to validate MR analysis. Donor site complications were recorded in patients undergoing modified SF closure. RESULTS Sixty-six patients were included in the retrospective MR imaging analysis; this revealed an average attenuation of SF of 4.7 cm (SEM = 0.25 cm), 4.5 cm (SEM = 0.23 cm), 4.6 cm (SEM = 0.23 cm), and 4.2 cm (SEM = 0.22 cm) to the left of, right of, cranial to, and caudal to the umbilicus, respectively. The mean surface area of radiologic SF absence was 56.3 cm 2 (SEM = 3.57 cm 2 ). There was a significant difference in SF presentation based on patient age ( P = 0.013) and body mass index ( P = 0.005). Five of the 66 patients (7.6%) experienced abdominal closure site complications. CONCLUSIONS This study objectively confirms that there is attenuation of SF in the periumbilical region, describes a novel SF closure technique, and provides evidence to support its adoption when closing transverse abdominal wall incisions.
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Affiliation(s)
- Uchechukwu O Amakiri
- From the Division of Plastic and Reconstructive Surgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | | | - Annet Kuruvilla
- From the Division of Plastic and Reconstructive Surgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Taylor J Ibelli
- From the Division of Plastic and Reconstructive Surgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Gabrielle Hernaiz-De Jesús
- From the Division of Plastic and Reconstructive Surgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Alexander Kagen
- Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Peter W Henderson
- From the Division of Plastic and Reconstructive Surgery, Icahn School of Medicine at Mount Sinai, New York, NY
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Carslaw CH, Samudrala H, Kerrison J, Brooker JE, Rabey NG, Malata CM. Increased Production of Abdominal Donor Site Fluid Following Microsurgical Breast Reconstruction With Superficial Inferior Epigastric Artery Versus Deep Inferior Epigastric Artery Perforator Flaps. Cureus 2023; 15:e38942. [PMID: 37313097 PMCID: PMC10259683 DOI: 10.7759/cureus.38942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/11/2023] [Indexed: 06/15/2023] Open
Abstract
Introduction and aims Donor site seroma following abdominal flap harvest for breast reconstruction is common in both deep inferior epigastric artery perforator (DIEP) and superficial inferior epigastric artery (SIEA) flaps. We tested the hypothesis that there is increased donor site fluid following SIEA dissection compared to DIEP. Materials and methods Of60 SIEA breast reconstructions performed by one surgeon in 50 patients (2004-2019), complete data were available for 31 patients. Eighteen unilateral SIEAs were matched with 18 unilateral DIEPs. Thirteen bilateral flap harvests involving an SIEA were matched with 13 bilateral DIEP controls. Their cumulative abdominal drain outputs, times to drain removal, hospital stay, and number and volume of seroma aspirations were compared. Results Patients who underwent an SIEA flap harvest had significantly increased drain output compared to only a DIEP flap harvest (SIEA=1,078 mL, DIEP=500 mL, p<0.001), which remained significant after controlling for confounding variables (p=0.002). There was increased time until drain removal (SIEA=11 days, DIEP=6 days, p=0.010), and patients who underwent an SIEA harvest were 14 times more likely to be discharged with a drain in situ (odds ratio (OR)=14.6, 95% confidence interval (CI)=2.8203-75.9565, p=0.0014). There was no significant difference in the number or volume of outpatient aspirations, length of hospital admission, or total seroma volume. Conclusion This study demonstrated that SIEA harvest is a significant predictor of increased abdominal drain output postoperatively. This accounted for longer periods before drain removal and more patients discharged with an abdominal drain in situ and should be an important consideration for reconstructive surgeons. There was no demonstrable difference in the number or volume of seroma aspirations after drain removal for either group.
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Affiliation(s)
- Calum H Carslaw
- School of Clinical Medicine, University of Cambridge, Cambridge, GBR
- Department of Intensive Care, Royal Papworth Hospital NHS Foundation Trust, Cambridge, GBR
| | - Havish Samudrala
- School of Clinical Medicine, University of Cambridge, Cambridge, GBR
| | - James Kerrison
- School of Clinical Medicine, University of Cambridge, Cambridge, GBR
| | - Jack E Brooker
- School of Clinical Medicine, University of Cambridge, Cambridge, GBR
| | - Nicholas G Rabey
- Department of Plastic and Reconstructive Surgery, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge, GBR
| | - Charles M Malata
- School of Medicine, Anglia Ruskin University, Cambridge, GBR
- Department of Plastic and Reconstructive Surgery, and Cambridge Breast Unit, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge, GBR
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Bigdeli AK, Momeni A, Kneser U. [Increasing Safety in Microsurgical Breast Reconstruction - Technique and Technology]. HANDCHIR MIKROCHIR P 2022; 54:314-325. [PMID: 35785806 DOI: 10.1055/a-1858-5214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Microsurgical reconstruction has established itself as a standard procedure in breast reconstruction as it permits creation of a natural and aesthetically appealing breast mound, even after modified radical mastectomy and radiation. In the past few decades numerous new free flap donor-sites have been described that permit an individualized approach to reconstruction, thus, resulting in a high level of patient satisfaction. Paralleling these technical innovations, the focus of microsurgical breast reconstruction has shifted from mere "flap success" to "aesthetic outcome", while also taking into account the respective donor-site morbidity. Here, the authors discuss contemporary developments in the field with a particular focus on surgical techniques and technologies that contribute to increasing the safety of microsurgical breast reconstruction.
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Affiliation(s)
- Amir Khosrow Bigdeli
- Klinik für Hand-, Plastische und Rekonstruktive Chirurgie - Schwerbrandverletztenzentrum BG Klinik Ludwigshafen, Ludwigshafen, Germany.,Klinik für Hand- und Plastische Chirurgie der Ruprecht-Karls-Universität Heidelberg Heidelberg, Heidelberg, Germany
| | - Arash Momeni
- Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Ulrich Kneser
- Klinik für Hand-, Plastische und Rekonstruktive Chirurgie - Schwerbrandverletztenzentrum BG Klinik Ludwigshafen, Ludwigshafen, Germany.,Klinik für Hand- und Plastische Chirurgie der Ruprecht-Karls-Universität Heidelberg Heidelberg, Heidelberg, Germany
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Robotic Harvest of the Deep Inferior Epigastric Perforator Flap for Breast Reconstruction: A Case Series. Plast Reconstr Surg 2022; 149:1073-1077. [PMID: 35255056 DOI: 10.1097/prs.0000000000008988] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND Robotic surgery is emerging as a viable tool in reconstructive surgery. Harvesting of the deep inferior epigastric perforator flap is typically performed through an anterior approach, which involves a long fascial incision. A robotic approach allows the deep inferior epigastric pedicle to be harvested from the posterior surface. This approach reduces the length of the fascial incision and should decrease the abdominal morbidity associated with large fascial dissections. METHODS A case series study of 21 patients who underwent a robotic deep inferior epigastric perforator or during a 12-month period for breast reconstruction was performed. Patient demographics, surgical characteristics, and complications were assessed. RESULTS Mean patient age was 54.6 ± 7.6 years, and mean body mass index was 30.4 ± 3.9 kg/m2. Mean fascial incision and pedicle length were 3.6 ± 1.6 cm and 13.3 ± 1 cm, respectively. None of the patients required conversion to open harvest. Mean length of hospital stay was 3.8 ± 0.9 days. Surgical site occurrences were identified in five patients (31.3 percent). One patient had delayed wound healing at the donor site. None of the patients developed hernia or bulge. The mean benefit (B = C - A), defined as length of fascial incision spared and measured as the difference between pedicle length and intramuscular course, was 9.83 ± 2.28 cm. The precision of computed tomography angiography in identifying the intraoperative fascial incision was 86 percent. CONCLUSION The robotic deep inferior epigastric perforator flap is a safe and reliable technique that decreases the length of fascial incision and short-term complications associated with the open approach. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.
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10
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Recent progress of collagen, chitosan, alginate and other hydrogels in skin repair and wound dressing applications. Int J Biol Macromol 2022; 208:400-408. [PMID: 35248609 DOI: 10.1016/j.ijbiomac.2022.03.002] [Citation(s) in RCA: 113] [Impact Index Per Article: 56.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Revised: 03/01/2022] [Accepted: 03/01/2022] [Indexed: 02/05/2023]
Abstract
Human understanding of skin is constantly ongoing. Great progress has been made in skin repair, wound dressing regeneration biomaterials research in recent years. This review introduced the clinical research and guiding principles of skin repair, wound dressing biomaterials at home and abroad, introduced the classification of various skin repair and wound dressing, listed the composition and performance of different dressing biomaterials, including traditional, natural, synthetic, tissue-engineered dressing materials were extensively reviewed. The biological molecular structures and biological function characteristics of different dressing biomaterials are comprehensively reviewed. Collagen, chitosan, alginate hydrogels et al. as the most popular biological macromolecules in skin repair and wound dressing applications were reviewed. The future development direction is also prospected. This paper reviews the research progress of advanced functional skin repair and wound dressing, which provides a reference for the modifications and applications of wound dressings.
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11
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Hilven PH, Vandevoort M, Bruyninckx F, De Baerdemaeker R, Dupont Y, Peeters Q, Nanhekhan L, Fabre G. Limiting the fascia incision length in a DIEP flap: Repercussion on abdominal wall morbidity. J Plast Reconstr Aesthet Surg 2021; 75:1108-1116. [PMID: 34903492 DOI: 10.1016/j.bjps.2021.11.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 11/03/2021] [Indexed: 10/19/2022]
Abstract
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.
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Affiliation(s)
- Paulien H Hilven
- Department of Plastic and Reconstructive Surgery; University Hospitals Leuven; Belgium
| | - Marc Vandevoort
- Department of Plastic and Reconstructive Surgery; University Hospitals Leuven; Belgium; Department of Plastic and Reconstructive Surgery; AZ Delta Roeselare; Belgium.
| | - Frans Bruyninckx
- Department of Physiotherapy and Revalidation; University Hospitals Leuven; Belgium
| | - Randy De Baerdemaeker
- Department of Plastic and Reconstructive Surgery; University Hospitals Leuven; Belgium
| | - Yamina Dupont
- Department of Plastic and Reconstructive Surgery; University Hospitals Leuven; Belgium
| | - Quinten Peeters
- Department of Plastic and Reconstructive Surgery; University Hospitals Leuven; Belgium
| | - Lloyd Nanhekhan
- Department of Plastic and Reconstructive Surgery; University Hospitals Leuven; Belgium
| | - Gerd Fabre
- Department of Plastic and Reconstructive Surgery; University Hospitals Leuven; Belgium; Department of Plastic and Reconstructive Surgery; AZ Delta Roeselare; Belgium
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12
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Khattab NR. Complications of free bipedicled DIEP flaps in breast reconstruction: a systematic review and meta-analysis. EUROPEAN JOURNAL OF PLASTIC SURGERY 2021. [DOI: 10.1007/s00238-021-01862-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Zoccali G, Farhadi J. Abdominal perforator exchange flap (APEX): A classification of pedicle rearrangements. Microsurgery 2021; 41:607-614. [PMID: 34387913 DOI: 10.1002/micr.30796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 04/27/2021] [Accepted: 08/05/2021] [Indexed: 11/10/2022]
Abstract
INTRODUCTION Abdominal-based reconstruction is the most commonly performed method for breast reconstruction after mastectomy using the patient's own tissues. DIEP flap has allowed to reduce the donor site morbidity but the incidence of bulging or hernia remains still high, especially when flap is based on multiple perforators. Abdominal Perforator Exchange flap (APEX) represents a further step forward in preserving the abdominal wall structures by disassembling the pedicle components and their reconstitution at the end of the dissection. In this study, we explore the possible anatomical configurations of perforators exchange for APEX, providing a simple classification of perforators reconstitution patterns and the possible clinical implications. MATERIALS AND METHODS A retrospective study was conducted on patients who received APEX flap for abdominal based breast reconstruction. Preoperative CT scans and procedure descriptions were analyzed to identify the vascular patterns during flap harvesting and the pedicle reconstitution sites. The onset of abdominal wall and flap related complications were investigated. RESULTS APEX flap was performed on 51 women and four vascular patterns were identified. We identified the Type A pattern in 36 cases (70.6%), the Type B pattern in 8 (15.7%), and the Type C pattern in 5 (9.8%). We performed an extra-anatomical reanastomosis (Type D) in only two case (3.9%) (p = .09). We recorded anastomotic problems in five pedicles' reconstitution and the odds ratio showed a possible correlation between the localization of pedicle division and the anastomosis problems (p > .05). No total or partial flap loss was recorded during this study. Marginal fat necrosis was clinically observed in three cases, which had very large flaps. No bulging or hernia was recorded. CONCLUSION Our perforators exchange classification for abdominal-based flap helps clinician in planning the surgery and also in describing the procedure easily allowing a more efficient communication. This classification could be used to approach perforator flaps with multiple vessels at other anatomical locations as well.
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Affiliation(s)
- Giovanni Zoccali
- Plastic and Reconstructive Surgery Department, Queen Victoria Hospital, East Grinstead, UK
| | - Jian Farhadi
- Plastic Surgery Group, Zurich, Switzerland.,University of Basel, Faculty of Medicine, Basel, Switzerland
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Siegwart LC, Sieber L, Fischer S, Diehm Y, Hirche C, Kneser U, Kotsougiani-Fischer D. The Use of Semi-Absorbable Mesh and its Impact on Donor-Site Morbidity and Patient-Reported Outcomes in DIEP Flap Breast Reconstruction. Aesthetic Plast Surg 2021; 45:907-916. [PMID: 33469702 DOI: 10.1007/s00266-020-02096-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 12/10/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND This study aimed to evaluate the impact of semi-absorbable mesh on donor-site morbidity and patient-reported outcomes in deep inferior epigastric perforator (DIEP) flap breast reconstruction. METHODS We conducted a retrospective cohort study of all patients who had DIEP flap breast reconstruction in our department from July 2007 to March 2019. Patients were invited to a comparative follow-up visit and grouped according to donor-site closure: primary fascial closure (the no-mesh group) and fascial reinforcement with semi-absorbable mesh in a subfascial position (the mesh group). The primary outcome of interest was donor-site morbidity, including bulging, hernia formation and rectus abdominis muscle strength. We also surveyed, surgical site complications and patient-reported outcomes using Patient and Observer Scar Assessment Scale v2.0 and BREAST-Q© version 2.0. RESULTS A total of 191 patients had received DIEP flap breast reconstruction. Eighty-five patients (44.5%) with 108 DIEP flaps (53 patients in the mesh group and 32 patients in the no-mesh group) were included in the study. The mean BMI of the patients was significantly higher in the mesh group (mesh group, 26.9 vs. no-mesh group, 25.0, with p = 0.03). The incidence of hernia was significantly reduced in the mesh group (mesh group, 2.8% vs. no-mesh group, 13.5%, with p = 0.03). The incidence of bulging and the extent of rectus abdominis muscle strength were similar for both groups. Operative surgical site complications were reduced in the mesh group (mesh group, 7.5% vs. no-mesh group, 18.8%). There was no difference in patients' physical well-being and satisfaction with the donor site between groups. Patient-reported scar outcome was significantly better in the no-mesh group (p < 0.001). CONCLUSION Our novel method of donor-site closure with semi-absorbable mesh in a subfascial position for reinforcement of the anterior rectus fascia on the DIEP donor site is safe. It has no negative impact on surgical site complications and patient-reported outcomes, while reducing the incidence of hernias on the donor-site in DIEP flap breast reconstruction. LEVEL OF EVIDENCE IV 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 .
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Affiliation(s)
- L C Siegwart
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Trauma Center Ludwigshafen, Hand and Plastic Surgery of the University of Heidelberg, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Germany
| | - L Sieber
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Trauma Center Ludwigshafen, Hand and Plastic Surgery of the University of Heidelberg, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Germany
| | - S Fischer
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Trauma Center Ludwigshafen, Hand and Plastic Surgery of the University of Heidelberg, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Germany
| | - Y Diehm
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Trauma Center Ludwigshafen, Hand and Plastic Surgery of the University of Heidelberg, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Germany
| | - C Hirche
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Trauma Center Ludwigshafen, Hand and Plastic Surgery of the University of Heidelberg, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Germany
| | - U Kneser
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Trauma Center Ludwigshafen, Hand and Plastic Surgery of the University of Heidelberg, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Germany
| | - D Kotsougiani-Fischer
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Trauma Center Ludwigshafen, Hand and Plastic Surgery of the University of Heidelberg, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Germany.
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15
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Salibian AA, Nolan IT, Bekisz JM, Frey JD, Karp NS, Choi M, Levine JP, Thanik VD. A Systematic Review and Meta-Analysis of Microvascular Stacked and Conjoined-Flap Breast Reconstruction. J Reconstr Microsurg 2021; 37:631-642. [PMID: 33592635 DOI: 10.1055/s-0041-1723820] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Stacked and conjoined (SC) flaps are a useful means of increasing flap volume in autologous breast reconstruction. The majority of studies, however, have been limited to smaller, single-center series. METHODS A systematic literature review was performed to identify outcomes-based studies on microvascular SC-flap breast reconstruction. Pooled rates of flap and operative characteristics were analyzed. Meta-analytic effect size estimates were calculated for reconstructive complication rates and outcomes of studies comparing SC flaps to non-SC flaps. Meta-regression analysis identified risk factors for flap complications. RESULTS Twenty-six studies were included for analysis (21 case series, five retrospective cohort studies) for a total of 869 patients, 1,003 breasts, and 2006 flaps. The majority of flaps were harvested from the bilateral abdomen (78%, 782 breasts) followed by combined abdomen-thigh stacked flaps (22.2%, 128 breasts). About 51.1% of flaps were anastomosed to anterograde/retrograde internal mammary vessels (230 breasts) and 41.8% used internal mammary/intraflap anastomoses (188 breasts). Meta-analysis revealed a rate of any flap complication of 2.3% (95% confidence interval: 1.4-3.3%), Q-statistic value p = 0.012 (I 2 = 43.3%). SC flaps had a decreased risk of fat necrosis compared with non-SC flaps (odds ratio = 0.126, p < 0.0001, I 2 = 0.00%), though rates of any flap and donor-site complication were similar. Age, body mass index, flap weight, and flap donor site and recipient vessels were not associated with increased risk of any flap complication. CONCLUSION A global appraisal of the current evidence demonstrated the safety of SC-flap breast reconstruction with low complication rates, regardless of donor site, and lower rates of fat necrosis compared with non-SC flaps.
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Affiliation(s)
- Ara A Salibian
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health, New York, New York
| | - Ian T Nolan
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health, New York, New York
| | - Jonathan M Bekisz
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health, New York, New York
| | - Jordan D Frey
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health, New York, New York
| | - Nolan S Karp
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health, New York, New York
| | - Mihye Choi
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health, New York, New York
| | - Jamie P Levine
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health, New York, New York
| | - Vishal D Thanik
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health, New York, New York
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16
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The Use of the Bipedicled Deep Inferior Epigastric Perforator Flap for Unilateral Breast Reconstruction: A Systematic Review and Meta-analysis. Ann Plast Surg 2020; 85:e66-e75. [PMID: 33165117 DOI: 10.1097/sap.0000000000002456] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
INTRODUCTION The use of abdominal flaps is recognized as a very advantageous approach for breast reconstruction with gradual refinements leading from the pedicled transverse rectus abdominis musculocutaneous flap to the criterion standard deep inferior epigastric perforator (DIEP) flap and its several variations. A systematic review with meta-analysis attempts to investigate the safety of the bipedicled DIEP flap for unilateral breast reconstruction. METHODS The literature search used "PubMed" database, and a relevant study conducted at the Queen Victoria Hospital was also included. The extraction of data included study type, follow-up, patients' age, body mass index, preexisting abdominal scars, timing of reconstruction, operating time, flap inset, pedicles' configuration, flap failure, revision, and complication rates. Proportions were pooled with Freeman-Tukey arcsine transformation, and meta-regression was performed to evaluate whether complication rates were modified by different variables. RESULTS Fourteen eligible articles provided an overall sample of 486 flaps, with a median follow-up of 18.5 months. In most cases, immediate reconstruction with undivided flap was performed, with equal use of extraflap and intraflap pedicles' configuration. Only 4 cases of flap failure (0.82%) were documented, with 18% overall complications and 3% fat necrosis rate. The forest plot showed significant between-study heterogeneity, and meta-regression revealed marginal positive association between older patient and complication rate. CONCLUSIONS Bipedicled DIEP flap for unilateral breast reconstruction is a technique that maintains the complications rate relatively low in challenging postmastectomy cases. Further comparative studies are needed to substantiate the findings of this study.
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17
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Salibian AA, Bekisz JM, Frey JD, Nolan IT, Kaoutzanis C, Yu JW, Levine JP, Karp NS, Choi M, Thanik VD. Comparing outcomes between stacked/conjoined and non-stacked/conjoined abdominal microvascular unilateral breast reconstruction. Microsurgery 2020; 41:240-249. [PMID: 32997369 DOI: 10.1002/micr.30659] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 08/29/2020] [Accepted: 09/10/2020] [Indexed: 11/06/2022]
Abstract
BACKGROUND Stacked and conjoined free flaps are increasingly utilized in autologous breast reconstruction to augment tissue transfer volume. However, there is a paucity of comparative data on abdominally-based stacked/conjoined versus non-stacked/conjoined flaps. The purpose of this study was to compare ability to match native breast size, complications, recovery, and symmetrizing procedures between these two cohorts in unilateral breast reconstruction. METHODS A retrospective review of all stacked (two separate hemiabdominal)/conjoined (bipedicled full abdominal) flaps and non-stacked/conjoined (unipedicled hemiabdominal) flaps in unilateral abdominally-based autologous breast reconstructions was performed from 2011 to 2018. Variables including demographics, operative characteristics, complications, and revisions were compared in 36 stacked/conjoined patients versus 146 non-stacked/conjoined patients. RESULTS The stacked/conjoined cohort had more DIEP flaps (91.7 vs. 65.1%) and the non-stacked/conjoined group more MS-TRAMs (34.2 vs. 6.9%, p = .000). Additionally, non-stacked/conjoined flaps had greater utilization of combined medial and lateral row perforators (p = .000). Mean flap weight was significantly higher than mastectomy weight in stacked/conjoined flaps (+110.7 g) when compared to non-stacked/conjoined flaps (-40.2) (p = .023). Average follow-up was 54.7 ± 27.5 and 54.6 ± 29.3 months, respectively. Stacked/conjoined flaps had lower fat necrosis rates (8.3 vs. 25.4%, p = .039) and had a decreased risk of fat necrosis on multivariable regression analysis (OR 0.278, p = 0.045). There were otherwise no differences in flap, breast, or donor-site complications. Stacked/conjoined flaps also had a lower rate of contralateral breast reduction (p = .041). CONCLUSION Stacked/conjoined flaps were associated with a lower risk of fat necrosis compared with non-stacked/conjoined flaps and had a lower rate of contralateral symmetrizing reductions in patients undergoing unilateral abdominally-based breast reconstruction.
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Affiliation(s)
- Ara A Salibian
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health, New York, New York, USA
| | - Jonathan M Bekisz
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health, New York, New York, USA
| | - Jordan D Frey
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health, New York, New York, USA
| | - Ian T Nolan
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health, New York, New York, USA
| | - Christodoulos Kaoutzanis
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health, New York, New York, USA
| | - Jason W Yu
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health, New York, New York, USA
| | - Jamie P Levine
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health, New York, New York, USA
| | - Nolan S Karp
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health, New York, New York, USA
| | - Mihye Choi
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health, New York, New York, USA
| | - Vishal D Thanik
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health, New York, New York, USA
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18
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Siotos C, Aravind P, Prasath V, Rubano A, Youssef M, Habibi M, Manahan MA, Cooney CM, Rosson GD. Pure fat grafting for breast reconstruction: An alternative autologous breast reconstruction. Breast J 2020; 26:1788-1792. [PMID: 32945041 DOI: 10.1111/tbj.13887] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2019] [Revised: 04/27/2020] [Accepted: 04/29/2020] [Indexed: 11/29/2022]
Abstract
Plastic surgeons offer various options for breast reconstruction based on patient preference, underlying disease, and comorbidities. An alternative form of breast reconstruction exists, which includes tissue expansion with tissue expander and subsequent fat grafting without the use of implant or flap. We retrospectively reviewed the breast cancer patients who underwent breast reconstruction at our institution to identify those with pure fat grafting. Demographic information, complications, operative details, and BREAST-Q scores were abstracted. From 2010-2015, 10 patients were identified. Patients with unilateral or bilateral mastectomy followed by pure fat grafting had a median of 3.5 or 4 sessions and a total median fat grafting volume of 380 or 974.5 cc, respectively. Patients were followed for 12 months, and no complications or breast cancer recurrences were noted. Finally, BREAST-Q scores at the 12-month follow-up were comparable to the preoperative values.
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Affiliation(s)
- Charalampos Siotos
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Division of Plastic and Reconstructive Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Pathik Aravind
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Vishnu Prasath
- Department of General Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Amanda Rubano
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Mohanad Youssef
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Mehran Habibi
- Department of General Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Michele A Manahan
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Carisa M Cooney
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Gedge D Rosson
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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19
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Christopoulos G, Berner JE, Sergentanis TN, Blackburn A, Mackey SP. The use of bi-pedicled DIEP flap for unilateral breast reconstruction: a 5-year retrospective study. EUROPEAN JOURNAL OF PLASTIC SURGERY 2020. [DOI: 10.1007/s00238-020-01742-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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20
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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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21
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Mohan AT, Zhu L, Vijayasekaran A, Saint-Cyr M. Autologous Breast Reconstruction in Low Body Mass Index Patients: Strategies for Maximizing Skin Envelope and Breast Volume. Clin Plast Surg 2020; 47:611-619. [PMID: 32892804 DOI: 10.1016/j.cps.2020.07.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Pure autologous breast reconstruction in thin patients creates challenges. This review highlights techniques to optimize the scarce donor tissue available, approaches to reconstruction, and microsurgical techniques. A systematic approach to maximize breast volume and the skin envelope in patients who underwent pure autologous breast reconstruction by a single senior surgeon is presented with a clinical case series. Included in the study were 125 patients (217) with autologous breast reconstructions. Although DIEP flaps were the commonest flap used overall (79%), within in the low body mass index (<22) group, there was a greater use of Latissimus (32%), and thigh-based flaps (>50%).
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Affiliation(s)
- Anita T Mohan
- Division of Plastic Surgery, Mayo Clinic, Mayo Building 12th Floor, 200 First Street Southwest, Rochester, MN 55905, USA. https://twitter.com/MNanitatmohan
| | - Lin Zhu
- Division of Plastic Surgery, Mayo Clinic, Mayo Building 12th Floor, 200 First Street Southwest, Rochester, MN 55905, USA
| | - Aparna Vijayasekaran
- Division of Plastic Surgery, Mayo Clinic, Mayo Building 12th Floor, 200 First Street Southwest, Rochester, MN 55905, USA
| | - Michel Saint-Cyr
- Division of Plastic Surgery, Baylor Scott & White, 2401 South 31st Street, Temple, TX 76508, USA.
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Brorson F, Thorarinsson A, Kölby L, Elander A, Hansson E. Early complications in delayed breast reconstruction: A prospective, randomized study comparing different reconstructive methods in radiated and non-radiated patients. Eur J Surg Oncol 2020; 46:2208-2217. [PMID: 32807615 DOI: 10.1016/j.ejso.2020.07.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 06/25/2020] [Accepted: 07/08/2020] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND There is little high-quality scientific evidence identifying the best and safest methods for delayed breast reconstruction, with most previous studies retrospective in nature. The primary aim was to compare early complication rates for two different breast-reconstructive methods in radiated and non-radiated patients, using a validated scale. The secondary aim was to identify predictors for complications. MATERIALS AND METHODS This study represents a clinical, randomized, prospective trial (ClinicalTrials.Gov identifier: NCT03963427), where the patients were divided into two study arms: non-radiated and radiated. In the non-radiated arm, patients were randomized to a one-stage lateral thoracodorsal flap with an implant or two-stage expander reconstruction. In the radiated arm, patients were randomized to a latissimus dorsi reconstruction combined with an implant or deep inferior epigastric artery perforator (DIEP) reconstruction. All adverse events were classified according to Clavien-Dindo and summarization of overall morbidity was performed by calculating the Comprehensive Complication Index score. The study was conducted from 2008 to 2020. RESULTS The complication frequencies were similar for the two surgical methods within each arm. In the non-radiated arm, risk factors for any complication were any comorbidities, and in the radiated arm, factors were a high body mass index and a contralateral operation. CONCLUSIONS The usage of the Clavien-Dindo scale in reconstructive surgery is feasible, but further validation is needed. In non-radiated patients, the frequencies of short-term complications were similar for lateral thoracodorsal flap and expander reconstruction, whereas in radiated patients, they were similar for DIEP and latissimus dorsi. The complication profile of the methods varied.
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Affiliation(s)
- Fredrik Brorson
- Department of Plastic Surgery, University of Gothenburg, The Sahlgrenska Academy, Institute of Clinical Sciences, Sahlgrenska University Hospital, Gothenburg, Sweden.
| | - Andri Thorarinsson
- Department of Plastic Surgery, University of Gothenburg, The Sahlgrenska Academy, Institute of Clinical Sciences, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Lars Kölby
- Department of Plastic Surgery, University of Gothenburg, The Sahlgrenska Academy, Institute of Clinical Sciences, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Anna Elander
- Department of Plastic Surgery, University of Gothenburg, The Sahlgrenska Academy, Institute of Clinical Sciences, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Emma Hansson
- Department of Plastic Surgery, University of Gothenburg, The Sahlgrenska Academy, Institute of Clinical Sciences, Sahlgrenska University Hospital, Gothenburg, Sweden.
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Grünherz L, Keijzer W, Uyulmaz S, Fertsch S, Imhof L, Käser S, Farhadi J, Lindenblatt N. Donor site aesthetics and morbidity after DIEP flap breast reconstruction—A retrospective multicenter study. Breast J 2020; 26:1980-1986. [DOI: 10.1111/tbj.14003] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Revised: 07/13/2020] [Accepted: 07/15/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Lisanne Grünherz
- Department of Plastic Surgery and Hand Surgery University Hospital Zurich Zurich Switzerland
| | - Welmoed Keijzer
- Department of Plastic and Reconstructive Surgery Guy’s and St. Thomas Hospital London UK
- Plastic Surgery Group Zurich Switzerland
| | - Semra Uyulmaz
- Department of Plastic Surgery and Hand Surgery University Hospital Zurich Zurich Switzerland
| | - Sonia Fertsch
- Department of Plastic Surgery and Hand Surgery University Hospital Zurich Zurich Switzerland
- Plastic Surgery Group Zurich Switzerland
| | - Laurence Imhof
- Department of Dermatology University Hospital Zurich Zurich Switzerland
| | - Samuel Käser
- Department of Visceral and Transplantation Surgery University Hospital Zurich Zurich Switzerland
| | - Jian Farhadi
- Department of Plastic and Reconstructive Surgery Guy’s and St. Thomas Hospital London UK
- Plastic Surgery Group Zurich Switzerland
| | - Nicole Lindenblatt
- Department of Plastic Surgery and Hand Surgery University Hospital Zurich Zurich Switzerland
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24
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Bilateral Simultaneous Breast Reconstruction with DIEP- and TMG Flaps: Head to Head Comparison, Risk and Complication Analysis. J Clin Med 2020; 9:jcm9072031. [PMID: 32605294 PMCID: PMC7409039 DOI: 10.3390/jcm9072031] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Revised: 06/11/2020] [Accepted: 06/16/2020] [Indexed: 11/16/2022] Open
Abstract
Background: A two center retrospective cohort study of simultaneous bilateral breast reconstructions using double deep inferior epigastric perforator (DIEP) flaps and double transverse myocutaneous/upper gracilis (TMG) flaps was conducted. The aim of this study was to compare surgical procedures, complications, and overall outcome. Patients and Methods: Two study groups, either receiving a simultaneous bilateral breast reconstruction, with double DIEP flaps (n = 152) in group 1, or double TMG flaps (n = 86) in group 2, were compared. A detailed risk and complication analysis was performed. Patient characteristics, operative time and the need for further operations were evaluated. Results: Double DIEP patients had donor site complications in 23.7% and double TMG patients in 16.3% (p = 0.9075, RR 1.45). Flap loss rates of 3.5% (double TMG) and 2.6% (double DIEP) were recorded (p = 0.7071, RR 1.33). The need for postoperative lipofilling was significantly higher in double TMG patients (65.1% vs. 38.2 %, p = 0.0047, RR 1.71). Conclusion: Complication analysis favors the double DIEP procedure. Donor site morbidity was lower and less severe in the double TMG group. Later fat grafting was more frequently needed after double TMG reconstructions. Further studies, preferably of prospective nature, are needed to evaluate the benefit of bilateral simultaneous breast reconstructions.
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Miyamoto S, Arikawa M, Kagaya Y. The use of lower abdominal perforator flaps in soft‐tissue reconstruction after sarcoma resection. Microsurgery 2019; 40:353-360. [DOI: 10.1002/micr.30539] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Revised: 09/13/2019] [Accepted: 11/08/2019] [Indexed: 11/12/2022]
Affiliation(s)
- Shimpei Miyamoto
- Division of Plastic and Reconstructive Surgery National Cancer Center Hospital Tokyo Japan
| | - Masaki Arikawa
- Division of Plastic and Reconstructive Surgery National Cancer Center Hospital Tokyo Japan
| | - Yu Kagaya
- Division of Plastic and Reconstructive Surgery National Cancer Center Hospital Tokyo Japan
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Lindenblatt N, Gruenherz L, Farhadi J. A systematic review of donor site aesthetic and complications after deep inferior epigastric perforator flap breast reconstruction. Gland Surg 2019; 8:389-398. [PMID: 31538064 DOI: 10.21037/gs.2019.06.05] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background The deep inferior epigastric perforator flap (DIEP) has gained widespread popularity in autologous breast reconstruction due to its natural aesthetic results and muscle-sparing design. However, donor site results regarding aesthetic outcome are often less favorable. Despite several studies on surgical technique and improvements of flap harvest, only a small number of studies addressing donor site aesthetic exist. Methods A systematic review was performed on donor site aesthetic after DIEP flap harvest according to the PRISMA guidelines. Secondary interests were abdominal wall morbidity and complication rates in general. The following electronic databases were included to identify relevant studies: Medline, Embase, PubMed, Cochrane, and Web of Science. Results The search yielded 95 articles for full-text analysis, with only four key studies found on donor site aesthetic specifically. Regarding complication rates, the overall rate of abdominal hernia ranges from 0 to 7.1%. Abdominal bulging occurs in 2.3% to 33%. Besides abdominal wall integrity, wound dehiscence (12-39%), seroma (1-48%), hematoma (1-15%), infections (1-12%), fat necrosis (0-11%) and umbilical necrosis (2-3%) significantly impair donor site aesthetic. Conclusions This systematic review reveals that the topic of donor site aesthetic and potential improvement of results has largely been neglected in the past decade. This study provides a thorough evaluation of potential problems that plastic surgeons may encounter and includes recommendations to improve results.
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Affiliation(s)
- Nicole Lindenblatt
- Department of Plastic and Reconstructive Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Lisanne Gruenherz
- Department of Plastic and Reconstructive Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Jian Farhadi
- Department of Plastic and Reconstructive Surgery, Guy's and St. Thomas Hospital, London, UK.,Plastic Surgery Group, Zurich, Switzerland.,Department of Plastic and Reconstructive Surgery, University of Basel, Basel, Switzerland
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De Virgilio A, Iocca O, Di Maio P, Malvezzi L, Pellini R, Mercante G, Spriano G. Head and neck soft tissue reconstruction with anterolateral thigh flaps with various components: Development of an algorithm for flap selection in different clinical scenarios. Microsurgery 2019; 39:590-597. [DOI: 10.1002/micr.30495] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Revised: 06/21/2019] [Accepted: 06/28/2019] [Indexed: 01/13/2023]
Affiliation(s)
- Armando De Virgilio
- Otorhinolaryngology ‐ Head and Neck SurgeryHumanitas Clinical and Research Hospital‐IRCCS, Rozzano (MI) Italy
- Department of Biomedical SciencesHumanitas University, Pieve Emanuele (MI) Italy
| | - Oreste Iocca
- Otorhinolaryngology ‐ Head and Neck SurgeryHumanitas Clinical and Research Hospital‐IRCCS, Rozzano (MI) Italy
| | - Pasquale Di Maio
- Giovanni Borea Civil HospitalDepartment of Otolaryngology‐Head and Neck Surgery Sanremo Italy
| | - Luca Malvezzi
- Otorhinolaryngology ‐ Head and Neck SurgeryHumanitas Clinical and Research Hospital‐IRCCS, Rozzano (MI) Italy
| | - Raul Pellini
- Department of Otolaryngology‐Head and Neck SurgeryRegina Elena National Cancer Institute Rome Italy
| | - Giuseppe Mercante
- Otorhinolaryngology ‐ Head and Neck SurgeryHumanitas Clinical and Research Hospital‐IRCCS, Rozzano (MI) Italy
| | - Giuseppe Spriano
- Otorhinolaryngology ‐ Head and Neck SurgeryHumanitas Clinical and Research Hospital‐IRCCS, Rozzano (MI) Italy
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Han HH, Kang MK, Song SY, Lee HC, Kim EK, Eom JS. Volume change in the rectus abdominis muscle after deep inferior epigastric perforator flap harvest. J Plast Reconstr Aesthet Surg 2018; 71:1310-1316. [PMID: 30017669 DOI: 10.1016/j.bjps.2018.06.003] [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] [Received: 02/05/2018] [Revised: 05/04/2018] [Accepted: 06/10/2018] [Indexed: 10/28/2022]
Abstract
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.
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Affiliation(s)
- Hyun Ho Han
- Department of Plastic Surgery, Asan Medical Center, University of Ulsan, College of Medicine, 88, Olympic-Ro 43-Gil, Songpa-Gu, Seoul, South Korea
| | - Min Kyu Kang
- Department of Plastic Surgery, Asan Medical Center, University of Ulsan, College of Medicine, 88, Olympic-Ro 43-Gil, Songpa-Gu, Seoul, South Korea
| | - Sin Young Song
- Department of Plastic Surgery, Asan Medical Center, University of Ulsan, College of Medicine, 88, Olympic-Ro 43-Gil, Songpa-Gu, Seoul, South Korea
| | - Hyung Chul Lee
- Department of Plastic Surgery, Asan Medical Center, University of Ulsan, College of Medicine, 88, Olympic-Ro 43-Gil, Songpa-Gu, Seoul, South Korea
| | - Eun Key Kim
- Department of Plastic Surgery, Asan Medical Center, University of Ulsan, College of Medicine, 88, Olympic-Ro 43-Gil, Songpa-Gu, Seoul, South Korea
| | - Jin Sup Eom
- Department of Plastic Surgery, Asan Medical Center, University of Ulsan, College of Medicine, 88, Olympic-Ro 43-Gil, Songpa-Gu, Seoul, South Korea.
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See JL, Przybylska J, MacLennan L, Malata CM. Letter to the Editor regarding "Use of both anterograde and retrograde internal mammary vessels in the bipedicled deep inferior epigastric perforator flap for unilateral breast reconstruction". J Plast Reconstr Aesthet Surg 2018; 71:431-433. [PMID: 29329744 DOI: 10.1016/j.bjps.2017.12.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Accepted: 12/05/2017] [Indexed: 10/18/2022]
Affiliation(s)
- Jia Le See
- University of Auckland, Faculty of Medical and Health Sciences, Auckland, New Zealand
| | - Julia Przybylska
- Poznań University of Medical Sciences, Faculty of Medicine, Poznań, Poland
| | - Louise MacLennan
- Cambridge Breast Unit, Addenbrooke's University Hospital, Cambridge, UK; Department of Plastic and Reconstructive Surgery, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge, UK
| | - Charles M Malata
- Cambridge Breast Unit, Addenbrooke's University Hospital, Cambridge, UK; Department of Plastic and Reconstructive Surgery, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge, UK; Anglia Ruskin University School of Medicine, Chelmsford & Cambridge, UK.
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