A retrospective comparison of abdominal muscle strength following breast reconstruction with a free TRAM or DIEP flap

Abdominal Wall Reinforcement Using OviTex after Deep Inferior Epigastric Perforator Flap

Abdominal wall bulges and hernias are not uncommon complications following deep inferior epigastric perforator (DIEP) flap harvest. Abdominal wall reinforcement using synthetic meshes has been found to decrease bulges by up to 70%; however, such meshes can be associated with other issues such as seromas and infections. Reinforced tissue matrix (RTM) mesh can be used for abdominal wall reinforcement due to its ability to recruit fibroblasts and provide a scaffold for cellular proliferation. There is no literature on the use of OviTex mesh for abdominal wall reinforcement following DIEP flap harvest. Therefore, this study aimed to evaluate the efficacy and safety of its use in this setting.A retrospective review was performed on patients undergoing DIEP flap harvest between January 2020 and June 2023. Patients who had completed at least 12 months of follow-up visits were included. Descriptive, univariate, and multiple logistic regression analyses were completed.A total of 199 patients were included. The mean age at the time of surgery was 51.1 ± 10.0 years and the mean body mass index (BMI) was 30.2 ± 5.9 kg/m2. Abdominal wall reinforcement was completed in 85 (42.7%) patients. Patients who had OviTex placed developed fewer bulges compared to the non-mesh cohort (0% vs. 5.3%, p = 0.04). Furthermore, OviTex mesh did not increase adverse events and was not significantly different in seroma/hematoma rates when compared to the non-mesh cohort (10.6% vs. 5.3%, p = 0.26).This study demonstrates that OviTex mesh is safe and efficacious in reducing the rate of bulges following DIEP flap harvest without increasing other complications.

The effect of muscle defect size on donor site hernia and bulge after transverse rectus abdominis flap

BACKGROUND

Muscle sparing-transverse rectus abdominis flap has been widely used for breast reconstruction and the abdominal hernia or bulging at the donor site is relatively common complication. Previous studies have emphasized the fascial defects and the defect of muscle has been neglected. This study aims to investigate the relationship between the size of the rectus abdominis muscle defect and its impact on hernia or bulge formation after muscle sparing-transverse rectus abdominis flap.

MATERIALS AND METHODS

A retrospective study of patients undergoing unilateral or bilateral breast reconstruction with muscle sparing-transverse rectus abdominis myocutaneous flap was performed. We compared the patient group with postoperative abdominal hernia or bulging requiring surgery with the patient group without hernia. The surgical specific data of the size of rectus abdominis muscle defect, muscle sparing type and flap weight are analyzed.  Results: We conducted a survey on a total of 160 patients, of which six patients experienced abdominal hernia or bulging requiring surgery. Comparing patient group requiring surgical treatment for hernia or bulging with patient group without hernia, there was a significant difference of the width of rectus abdominis muscle defect. The cut-off value of the width was 4.5 cm.  Conclusion: When performing MS-TRAM, minimizing the resection of rectus abdominis muscle remains crucial, especially the horizontal width.

Intercostal nerve electrodiagnostic testing in rib fractures

INTRODUCTION/AIMS

Intercostal nerve injury can occur after rib fractures, resulting in denervation of the abdominal musculature. Loss of innervation to the rectus abdominis and intercostal muscles can cause pain, atrophy, and eventual eventration, which may be an underrecognized and thus undertreated complication of rib fractures. We investigated the clinical utility of intercostal nerve electrodiagnostic testing following rib fractures to diagnose and localize nerve injury at levels T7 and below.

METHODS

Five patients with displaced bicortical rib fractures involving the 7th-11th ribs and clinical eventration of the ipsilateral abdominal wall underwent intercostal nerve conduction studies (NCS) and needle electromyography (EMG) on the affected side. EMG of the rectus abdominis and intercostal muscles was performed with ultrasound guidance, and ultrasound measurements of rectus abdominis thickness were obtained to assess for atrophy.

RESULTS

Average patient age was 59.4 years and average body mass index (BMI) was 31.5 kg/m2. Intercostal NCS and EMG were able to reliably diagnose and localize intercostal nerve damage after rib fractures. Ultrasound demonstrated an average rectus abdominis transverse cross-sectional thickness of 0.534 cm on the affected side, compared with 1.024 cm on the non-affected side.

DISCUSSION

Intercostal electrodiagnostic studies can diagnose and localize intercostal nerve damage after displaced rib fractures. Musculoskeletal ultrasound can be used to diagnose and quantify rectus abdominis atrophy and to accurately and safely guide needle EMG to the intercostal and rectus abdominis muscles.

Robotic Repair: An Alternative Technique for Rectus Diastasis and Abdominal Bulge Following DIEP Flap Breast Reconstruction

BACKGROUND

The deep inferior epigastric artery perforator (DIEP) flap is the gold standard in autologous breast reconstruction. Despite advances in perforator dissection, abdominal morbidity still occurs. Traditional rectus diastasis (RD), abdominal bulge, and hernia repair with open techniques are associated with higher complication rates and recurrence.

OBJECTIVES

We present a novel case series of robotic repair of symptomatic RD and/or abdominal bulge with concurrent hernia following DIEP flap surgery.

METHODS

A single-center, retrospective review was conducted of 10 patients who underwent bilateral DIEP flap breast reconstruction and subsequent robotic repair of RD and/or abdominal bulge and hernia. Preoperative demographics and postoperative clinical outcomes were reviewed. RD up to 5 cm, abdominal bulge, and any concurrent ventral/umbilical hernias were repaired robotically with retrorectus plication and macroporous mesh reinforcement.

RESULTS

The average age and BMI were 49 years (range 41-63) and 31 kg/m2 (range 26-44), respectively. The average number of perforators harvested per flap was 2.5 (range 1-4). Average RD and hernia size were 3.95 cm (range 2-5) and 5.8 cm2 (1-15), respectively. Eight patients stayed 1 night in the hospital, and 2 went home the same day as the robotic repair. No patients were converted to open technique and none experienced complications within 30 days.

CONCLUSIONS

For patients who experience donor site morbidity following DIEP flap breast reconstruction, minimally invasive robotic repair of RD and/or abdominal bulge with hernia can be performed with mesh reinforcement. This technique is effective, with low complication rates, and should be considered over open repair.

LEVEL OF EVIDENCE: 4

Superficial Inferior Epigastric Artery Flap: Vascular Pattern and Territory Across the Midline

BACKGROUND

 Superficial inferior epigastric artery (SIEA) flap offers a significant advantage of lower donor site morbidity over other abdominal-based flaps for breast reconstruction. However, the inconsistent anatomy and territory across the midline remains a major issue. This study aimed to investigate the SIEA and determine its pattern and territory across the midline.

METHODS

 Twenty cadavers were studied. Ipsilateral dye was injected to the dominant SIEA. Dissection was performed to evaluate the SIEA origin, artery and vein pattern, vessel diameter, and dye diffusion territory.

RESULTS

 Overall, three SIEA patterns were identified: bilateral presence (45%), ipsilateral presence (30%), and bilateral absence (25%). The territory depended on the vessel course and dominant SIEA diameter, not on its common origin from the femoral artery, at the pubic tubercle level. Regarding the midline territory (pubic tubercle level to umbilicus), SIEA (type 1a) with a diameter of ≥1.4 mm on either side supplied at least half the distance, whereas SIEA with a diameter of <1 mm was limited to the suprapubic area.

CONCLUSION

 Designing a SIEA flap island across the midline is feasible when contralateral SIEA is present to augment the contralateral territory (e.g., type 1a SIEA) or in SIEA with a common/superficial external pudendal artery origin. Preoperative imaging studies are important for confirming the SIEA system. When the diameter at the origin of the SIEA flap is larger than 1.4 mm, the blood supply to the ipsilateral and contralateral sides is sufficient to enable safe flap elevation.

Transverse division of the rectus abdominis muscle in deep inferior epigastric perforator flap elevation: A rescue technique to include more than one perforator

BACKGROUND

It is important to include as many perforators as possible in order to enhance the vascularity of a deep inferior epigastric perforator (DIEP) flap. However, the rectus muscle must be transected transversely, which prevents suturing and can cause a defect along the same line as the muscle-sparing procedure. When harvesting the DIEP flap, no specific method was suggested to solve these muscle defects. We found that by transecting the rectus muscle transversely, the muscle could be sutured in the tendinous area more easily while maintaining muscle function. The purpose of this study is to confirm the long-term recovery of the rectus abdominis muscle through the volume change after DIEP flap using this tendinous transection and suture method.

PATIENTS AND METHODS

A retrospective review of 28 patients who underwent unilateral breast reconstruction using a DIEP flap and the tendinous transection method for multiple perforators between May 2018 and April 2020 was conducted. The preoperative and postoperative volumes of the rectus abdominis muscle were estimated both the harvest and opposite sides.

RESULTS

The preoperative and postoperative muscle volumes from the harvest side were 50.08 ± 8.71 cm3 and 48.56 ± 8.61 cm3, respectively. The volume difference was 1.522 cm3 decrease, which was not statistically significant (p = .070). The preoperative and postoperative muscle volumes from the opposite side were 50.50 ± 8.15 cm3 and 50.08 ± 8.18 cm3, respectively. The volume difference was 0.434 cm3 increase and was not statistically significant (p = .064). Postoperative volume changes in the rectus muscle were not statistically significant on either side.

CONCLUSION

The tendinous transection method in the DIEP flap procedure did not significantly affect postoperative rectus muscle volume. Therefore, we expect this harvest method to allow DIEP flap reconstruction that includes multiple perforators and complete donor muscle recovery.

[Robotic-Assisted DIEP Flap Harvest for Autologous Breast Reconstruction: Case Report, Technical Aspects and Identification of Suitable Patients]

BACKGROUND

Robotic-assisted harvest of the deep inferior epigastric perforator (DIEP) flap is an innovative modification of the traditional open preparation for autologous breast reconstruction. It is assumed that donor-site morbidity (herniae, bulging) is reduced by minimising the fascial incision length in robotic-assisted DIEP flap harvest.

MATERIAL & METHODS

This is the first report of a robotic-assisted DIEP harvest in Germany, which was performed in April 2023 at the University Hospital of Freiburg in an interdisciplinary approach of the Departments of Plastic Surgery, Urology and Gynaecology. To determine the value of this novel technique, we assessed the demand by retrospectively performing an analysis of potential patients and conducted a cost analysis based on the breast reconstructions with DIEP flap harvest performed between April 2021 and May 2023 at the Department of Plastic Surgery at Freiburg University Hospital. To this end, we carried out a retrospective analysis of preoperative CT angiographies to determine the proportion of patients suitable for a robotic-assisted procedure in a post-hoc analysis. Furthermore, we describe the basic robotic-assisted techniques and discuss the TEP and TAPP laparoscopic approaches.

RESULTS

In line with the previously published literature, a short intramuscular course (≤25 mm) and a perforator diameter of≥1.5 mm and≥2.7 mm (subgroup) were defined as a crucial condition for the robotic-assisted procedure. We analysed 65 DIEP flaps harvested in 51 patients, of which 26 DIEP flaps in 22 patients met both criteria, i. e.≤25 mm intramuscular course and≥1.5 mm diameter of the perforator, while 10 DIEP flaps in 10 patients additionally met the criteria of the subgroup (≥2.7 mm diameter). Based on the intramuscular course of the perforators in the CT angiographies of those 26 DIEP flaps, a potential reduction of the fascial incision of 96.8±25.21 mm (mean±standard deviation) compared with the conventional surgical approach was calculated. The additional material costs in our case were EUR 986.01. However, ischaemia time was 33,5 minutes longer than the median of the comparative cohort.

CONCLUSION

The robotic-assisted procedure has already proven to be a feasible alternative in a suitable patient population. However, further studies are needed to confirm that robotic-assisted DIEP flap harvest actually reduces harvest site morbidity and thereby justifies the additional costs and complexity.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Acromiothoracic Venous Supercharge for Abdominal-Based Free Flaps in Breast and Chest Wall Reconstruction

BACKGROUND

Supercharging the venous drainage of free abdominal flaps in breast reconstruction has been well described in the literature, with diverse options used to augment venous drainage. In this study, we present our experience in using the acromiothoracic vein (ATV)/thoracoacromial vein (TAV) as a secondary recipient vein for the superficial inferior epigastric vein (SIEV) of free, muscle-sparing transverse rectus abdominis myocutaneous flaps in breast and chest wall reconstruction.

PATIENTS AND METHODS

We retrospectively reviewed 523 free, muscle-sparing transverse rectus abdominis myocutaneous flaps the senior author (H.H.K.) performed between 2009 and 2022 for breast and chest wall reconstruction; 46 cases required venous super drainage. Seventeen patients had ipsilateral SIEV anastomosed into the second internal mammary vein, 5 had ipsilateral SIEV anastomosed into flap second deep inferior epigastric vein, and 24 required the use of the (ATV)/(TAV), which will be the focus of this study.

RESULTS

The study included 24 female (20 breast and 4 chest wall reconstruction) patients ranging in ages between 39 and 72 years. They had a median follow-up of 26 months. Combined muscle splitting and cutting techniques were used to expose the ATV/TAV. Increase in operative time ranged between 10 and 20 minutes (median, 12 minutes). Vein coupler sizes were 1.5 to 3 mm. The mean weight of the flap was 740 g (range, 460-1300 g). There was 1 flap failure (salvage with latissimus dorsi flap performed), whereas 23 flaps wholly survived.

CONCLUSIONS

The ATV/TAV is a suitable recipient for venous supercharging free flaps used to reconstruct breast and chest wall defects.

Dobutamine and Goal-Directed Fluid Therapy for Improving Tissue Oxygenation in Deep Inferior Epigastric Perforator (DIEP) Flap Breast Reconstruction Surgery: Protocol for a Randomized Controlled Trial

BACKGROUND

Breast reconstruction is an integral part of breast cancer care. There are 2 main types of breast reconstruction: alloplastic (using implants) and autologous (using the patient's own tissue). The latter creates a more natural breast mound and avoids the long-term need for surgical revision-more often associated with implant-based surgery. The deep inferior epigastric perforator (DIEP) flap is considered the gold standard approach in autologous breast reconstruction. However, complications do occur with DIEP flap surgery and can stem from poor flap tissue perfusion/oxygenation. Hence, the development of strategies to enhance flap perfusion (eg, goal-directed perioperative fluid therapy) is essential. Current perioperative fluid therapy is traditionally guided by subjective criteria, which leads to wide variations in clinical practice.

OBJECTIVE

The main objective of this trial is to determine whether the use of minimally invasive cardiac output (CO) monitoring for guiding intravenous fluid administration, combined with low-dose dobutamine infusion (via a treatment algorithm), will increase tissue oxygenation in patients undergoing DIEP flap surgery.

METHODS

With appropriate institutional ethics board and Health Canada approval, patients undergoing DIEP flap surgery are randomly assigned to receive CO monitoring for the guidance of intraoperative fluid therapy in addition to a low-dose dobutamine infusion (which potentially improves flap oxygenation) versus the current standard of care. The primary outcome is tissue oxygenation measured via near-infrared spectroscopy at the perfusion zone furthest from the perforator vessels 45 minutes after vascular reanastomosis of the DIEP flap. Low dose (2.5 μg/kg/hr) dobutamine infusion continues for up to 4 hours postoperatively, provided there are no associated complications (ie, persistent tachycardia). Flap oxygenation, hemodynamic parameters, and any medication-associated side effects/complications are monitored for up to 48 hours postoperatively. Complications, rehospitalizations, and patient satisfaction are also collected until 30 days postoperatively.

RESULTS

Funding and regulatory approvals were obtained in 2019, but the study recruitment was interrupted by the COVID-19 pandemic. As of October 4, 2023, 34 participants have been recruited. Because of the significant delays associated with the pandemic, the expected completion date was extended. We expect the study to be completed and ready for potential news release (as appropriate) and publication by July 2024. No patients have suffered any adverse effects/complications from participating in this study, and none have been lost to follow-up.

CONCLUSIONS

CO-directed fluid therapy in combination with a low-dose dobutamine infusion via a treatment algorithm has the potential to improve DIEP flap tissue oxygenation and reduce complications following DIEP flap breast reconstruction surgery. However, given that the investigators remain blinded to group randomization, no comment can be made regarding the efficacy of this intervention for improving tissue oxygenation at this time. Nevertheless, no patients have been withdrawn for safety concerns thus far, and compliance remains high.

TRIAL REGISTRATION

Clinicaltrials.gov NCT04020172; https://clinicaltrials.gov/study/NCT04020172.

Outcomes of leaflet-shaped acellular dermal matrix with a thickness-gradient for abdominal fascial defect repair in muscle-sparing TRAM flap-based breast reconstruction

BACKGROUND

Numerous fascial closure techniques have been used to reduce donor site morbidities after transverse rectus abdominis myocutaneous (TRAM) flap harvest. A leaflet-shaped acellular dermal matrix (ADM) with a thickness gradient was designed to cover the defect effectively and to withstand the pressure applied to the lower portion of the defect. The complication and functional recovery rates of the donor site of the custom ADM were compared with those of previous methods of fascial closure (primary closure and polypropylene mesh assisted closure).

MATERIALS AND METHODS

A retrospective review of patients undergoing immediate or delayed breast reconstruction using muscle-sparing TRAM flaps was performed. Abdominal bulging, hernia, wound dehiscence, infection, seroma, and hematoma rates were compared. The Back Performance Scale measured four months postoperatively was compared to evaluate the donor site's recovery rate.

RESULTS

A total of 173 patients were analyzed. The three groups did not differ in hernia, wound dehiscence, infection, and hematoma rates. However, the abdominal bulging rate was lower in the primary closure group, while the seroma rate was higher in the mesh group. Functional recovery was the fastest in the custom ADM group.

CONCLUSION

A thickness-gradient, leaflet-shaped ADM can be effectively used as an onlay graft to cover the abdominal fascial defect, with similar complication rates, while providing a faster recovery of abdominal function.

Ultrasonographic assessment of rectus abdominis muscle adaptation after deep inferior epigastric artery perforator (DIEP) flap surgery: Single institution retrospective study

The impact of deep inferior epigastric artery perforator (DIEP) flap on abdominal wall integrity has been the topic of an ongoing debate with previous studies having reported conflicting results using various imaging modalities. Ultrasonography is a noninvasive, cost-effective, and readily available method for evaluating the changes to the rectus muscle after DIEP flap surgery. In the present study, we aimed to compare rectus abdominis muscle thickness between the operated and non-operated sides using ultrasound imaging. The muscle thickness was measured at the cross point of the midclavicular line and the level of the umbilicus and anterior superior iliac spine using real-time B-mode ultrasonography. The muscle anteroposterior diameters of the pedicle-dissected side and the control side were compared using paired t test. In total 31 patients with a mean follow-up of 70.18 weeks were included. The mean diameters at the level of the umbilicus of the operated and non-operated sides were 8.16 ± 1.83 and 8.14 ± 1.43 mm, respectively (P = .94). The mean thicknesses at the anterior superior iliac spine level were 7.74 ± 1.85 on the flap harvested side and 8.04 ± 1.84 mm on the control side (P = .35). There was no statistically significant difference between the 2 groups. Ultrasonography can be a reliable, inexpensive, and easily usable modality for evaluating donor site complication following DIEP flap. DIEP flap seems to have minimal impact on the abdominal donor site, and it may be safe and versatile to reconstruct the breast after mastectomy.

The nuances of abdominal free flap harvest: Technical and patient factors affecting abdominal donor site morbidity in autologous breast reconstruction

INTRODUCTION

Abdominal donor site morbidity after autologous breast reconstruction is common and often underreported. This work aims to compare prospectively collected technical details of the procedure and patient factors and their impact on the development of symptomatic and asymptomatic abdominal bulges (ASB and SB).

METHODS

A review of patients undergoing abdominal-based autologous breast reconstruction from May 2012 to October 2017 by two surgeons at a single institution was performed. Demographics, prior medical and surgical history, intraoperative data, and postoperative course were collected. Primary outcomes of interest were ASB or SB and wound healing complications.

RESULTS

Overall, 196 free flaps from 117 patients were included. The average follow-up was 1.9 ± 1.7 years. Thirteen (11.1%) patients developed ASB, and 13 (11.1%) patients developed SB. Patients with BMI ≥ 30, bilateral ms-TRAM reconstruction, and an onlay type of abdominal closure were 2×, 2.3×, and 8.1× more likely to develop a bulge, respectively (p = 0.017, p = 0.010, p = 0.049). Every one-point increase in BMI above 30 increased the odds of developing a bulge by 10.8%. Prior abdominal surgery increased the risk of SB by 7-fold (p = 0.017). The size of the harvested muscle, use of mesh, or nerve preservation did not affect the rate of bulge development.

CONCLUSION

High BMI, bilateral ms-TRAM, onlay type of abdominal closure, and prior abdominal surgery increase the risk of ASB and SB development to varying degrees, while several other operative variables did not seem to make a difference. Breast reconstruction patients can use this information for preoperative counseling and intraoperative decision-making.

Complications of Immediate versus Delayed DIEP Reconstruction: A Meta-Analysis of Comparative Studies

Simple Summary

Although the deep inferior epigastric perforator flap (DIEP) has become the most frequent autologous flap in breast reconstruction, it remains unclear whether reconstruction should be performed at the same time as the mastectomy or delayed. Therefore, we conducted a meta-analysis to offer an overview of recipient site postoperative complications and help guide practicians toward the ideal timing for breast reconstruction. A pooled analysis using the Mantel and Haenszel methods with a fixed effect model provided results as an odd ratio with a 95% confidence interval. Among most complications including hematoma, infection, fat necrosis, and flap loss, no significant differences were observed. However, delayed wound healing was significantly higher for patients who underwent delayed breast reconstruction. This paper offers evidence that both surgical timings offer similar outcomes and are, therefore, valid surgical strategies.

Abstract

Purpose: The setting regarding the ideal timing for deep inferior epigastric perforator flap (DIEP) reconstruction remains unclear. Immediate breast reconstruction (IBR) is performed at the same time as mastectomy, while delayed breast reconstruction (DBR) is performed at any time after mastectomy except immediately. We compared both strategies to assess whether IBR or DBR should be performed to reduce postoperative adverse events. Methods: A systematic review of PubMed, Embase, Medline, Cochrane, and Web of Science was conducted, aiming at articles comparing the recipient site outcomes of IBR versus DBR with DIEP. We used the Mantel–Haenszel method with a fixed effects model. Results were expressed as the OR with a 95% CI. Results: Two retrospective and two prospective studies were identified involving 5784 DIEPs (1744 immediate and 4040 delayed). We showed a significant difference in favor of IBR for wound healing issues (OR = 0.57, 95% CI 0.41, 0.77; p = 0.0003). However, no significant differences for hematoma, infection, fat necrosis, partial flap loss, and total flap loss rate were seen. Conclusions: Despite variability in the choice of the ideal time for breast reconstruction and outcomes reported among studies, immediate DIEP surgery appears to be a reliable setting with less delayed healing issues.

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

BACKGROUND AND OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE III

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

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

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

Robotic Harvest of the Deep Inferior Epigastric Perforator Flap for Breast Reconstruction: A Case Series

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.

Comparing Donor Site Morbidity for Autologous Breast Reconstruction: Thigh vs. Abdomen

Although abdominally-based free flaps have long been the gold standard, the profunda artery perforator (PAP) flap has emerged as an important alternative option for autologous breast reconstruction. The aim of this study was to directly compare the donor site morbidity of using the PAP versus deep inferior epigastric perforator (DIEP) free flap.

Patient Management Strategies in Perioperative, Intraoperative, and Postoperative Period in Breast Reconstruction With DIEP-Flap: Clinical Recommendations

Background and Objective

Deep Inferior Epigastric Perforator (DIEP) flap is a tissue isolated from the skin and subcutaneous tissue of the lower abdomen or rectus muscle to foster breast reconstruction. There is limited information about DIEP-flap induced complications associated with breast reconstruction surgery.

Evidence

We conducted a systematic review of the published literature in the field of breast cancer reconstruction surgery. Information was gathered through internet resources such as PubMed, Medline, eMedicine, NLM, and ReleMed etc. The following key phrases were used for effective literature collection: “DIEP flap”, “Breast reconstruction”, “Patient management”, “Postoperative DIEP”, “Intraoperative anticoagulant therapy”, “Clinical recommendations”. A total of 106 research papers were retrieved pertaining to this systematic review.

Conclusion

A successful breast reconstruction with DIEP-flap without complications is the priority achievement for this surgical procedure. This study provides various evidence-based recommendations on patient management in the perioperative, intraoperative, and postoperative periods. The clinical recommendations provided in this review can benefit surgeons to execute breast reconstruction surgery with minimal postoperative complications. These recommendations are beneficial to improve clinical outcomes when performing surgery by minimizing complications in perioperative, intraoperative, and postoperative period.

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

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

Is Pregnancy Following a TRAM or DIEP Flap Safe? A Critical Systematic Review and Meta-analysis

BACKGROUND

Previous data were not conclusive on the safety of gestation in patients whose abdominal flaps were earlier harvested. We performed a meta-analysis to evaluate the abdominal wall complications and birth mode of pregnancy in post-TRAM or post-DIEP harvested individuals.

METHODS

A literature search was performed using the PubMed, Embase, Scopus, and Google scholar database. Heterogeneity was statistically analyzed, and random effect models were applied. Publication bias was assessed by funnel plot.

RESULTS

We included 25 papers that captured 56 patients giving birth to 69 healthy babies after elevation of abdominally based flaps, with a pooled abdominal complication rate of 0.00-0.09. The complication incidence in TRAM group was 0.01 (95% CI = [0.00-0.14%]) while 0.00 in the DIEP group (95% CI = [0.00-0.26%]). Discrepancies in incidence following unilaterally or bilaterally based TRAM flaps, following free or pedicled TRAM flaps, following primary sutured or mesh strengthened fascia, following MS free TRAM or conventional free TRAM could not be calculated as statistically significant. TRAM group and DIEP group patients had identical birth modes.

CONCLUSIONS

The present meta-analysis did not detect evidence that abdominal walls with the prior harvest of abdominal flaps could affect the process of pregnancy or contraindicate vaginal delivery. No abdominal hernia or bulge occurred with post-DIEP pregnancies. However, such conclusions need to be substantiated by larger sample studies.

LEVEL OF EVIDENCE III

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Destination Design msTRAM: For Greater Reconstructive Certainty

Performing delayed reconstruction to a unilateral breast while simultaneously performing a balancing procedure on the contralateral side can be the most difficult situation to achieve symmetry. We present here a novel approach to free TRAM-based breast reconstruction using reverse planning and subunit principles with simultaneous balancing reduction mastopexy and immediate nipple reconstruction.

The Use of Semi-Absorbable Mesh and its Impact on Donor-Site Morbidity and Patient-Reported Outcomes in DIEP Flap Breast Reconstruction

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 .

Do medial sural artery perforator flaps have better clinical outcomes compared to the rectus abdominis perforator (DIEAP) flap in reconstruction of glossectomy defects? A Prisma guided meta-analysis

BACKGROUND

There is an increasing evidence for the use of thin flaps based on vascular perforators for reconstructive surgeries. The medial sural and deep inferior epigastric artery flaps offer versatility for the reconstruction of major defects of the head and neck.

OBJECTIVES

"Whether medial sural artery perforator (MSAP) flap or rectus abdominis perforator flap is better for the reconstruction of glossectomy defects in terms of functional outcome?"

DATA SOURCES

PubMed, Cochrane Library, clinicaltrials.gov and hand searches.

PARTICIPANTS AND INTERVENTIONS

Patients who underwent tongue reconstruction with either MSAP flap or deep inferior epigastric artery perforator (DIEAP) flap.

STUDY APPRAISAL AND SYNTHESIS METHODS

Based on defined study criteria 6 studies were selected according to Prisma Guidelines. The overall estimated effect was categorized as significant where P < 0.05.

RESULTS

There was no significant difference between both flaps in terms of receptor site complications (P = 0.223). Overall odds ratio (OR) for complications was 1.35 (95% confidence interval [CI]: 0.412-0.736) and the test for overall effect t value was 2.836, P < 0.05. Overall OR was 6.01 (95% CI 0.5-7.45) and the test for overall effect t value was 1.41, P < 0.05 indicating there was a statistical difference in the intelligibility of speech.

LIMITATIONS

Anatomical variations, under-reporting of studies and lack of universal tool for speech intelligibility.

CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS

Both the flaps are comparable in terms of functional outcome. Medium-sized defects can be reconstructed with MSAP and composite larger defects would benefit from DIEAP. In females, anterolateral thigh flap still remains the choice for composite reconstructions.

Abdominal weakness, bulge, or hernia after DIEP flaps: An algorithm of management, prevention, and surgical repair with classification

BACKGROUND

This study analyzes abdominal weakness, hernia, and bulge following deep inferior epigastric perforator (DIEP) flap breast reconstruction. Abdominal wall morbidities are categorized, and an algorithm for management is provided.

METHODS

A retrospective review of 644 patients who underwent abdominal based flap breast reconstruction between 2009 and 2018 and met selection criteria was performed. Bulge and hernia were evaluated on exam and then by imaging and/or operative exploration. The incidence of abdominal weakness was evaluated by BREAST-Q™ data. Risk factors were analyzed.

RESULTS

Of the 644 patients, 23 (3.6%) had a clinically significant bulge or hernia on exam postoperatively. Developing an abdominal wound postoperatively and sacrificing nerves both correlated with an increased incidence of bulge or hernia (p < 0.05). The use of lateral row perforators, keeping the umbilicus, higher BMI, and the use of biological mesh in the initial abdominal wall repair trended toward an increased incidence of bulge or hernia; however, these data were not statistically significant. Seven percent of patients who answered the BREAST-Q™ reported abdominal weakness. Patients in the umbilicus sacrificing cohort had an increased incidence of weakness (p < 0.05). Abdominal wounds, nerve sacrificing procedures and obesity correlated with an increased incidence of weakness; these data were not statistically significant.

CONCLUSIONS

A classification and algorithm for treatment of functional abdominal wall morbidity after DIEP flap is provided. Abdominal wall morbidity is classified as: type 1 - abdominal weakness; type 2 - smaller, unilateral abdominal bulge; and type 3 - true abdominal hernia or large bilateral bulge. An algorithm of treatment is presented, which includes physical therapy and surgical repair recommendations.

An Idea of Hemi-abdominal Free Flap for Breast Reconstruction: A Case Report

A deep inferior epigastric perforator (DIEP) flap is one of the gold standards for autologous breast reconstructions. However, this flap cannot be chosen again if asynchronous contralateral breast cancer occurs in the future. To solve this problem, we propose an idea and design for a hemi-abdominal DIEP flap. The patient was a 50-year-old woman who was suffering from right invasive ductal carcinoma. In using a hemi-abdominal DIEP flap, the poor postoperative appearance of the donor site might be a problem. To obtain a good donor site shape, we use a specific design to make the appearance of the donor site as good as possible. Specifically, we make an oblique spindle-shaped flap that can cover the deep inferior epigastric perforators, the superficial circumflex iliac artery, and the superficial inferior epigastric artery and avoid dog-ears, without passing over the median line. The flap weight was 800 g, the operating time was 6 hours and 22 minutes, and the bleeding amount was 110 ml. The patient had a minor wound infection in the donor site, and it was treated with a local wound treatment. The patient is satisfied with the result. We believe our flap design could minimize the unfavorable appearance of the donor site. This method might be suited to cases where the patients present with excess skin and fat on the abdomen, and half the abdominal tissue is enough to create the necessary volume of the breast. Although more cases and studies will be required to justify our technique, this case may show the possibility of a new option for breast reconstructions.

Laparoscopy allows the harvest of the DIEP flap with shorter fascial incisions as compared to endoscopic harvest: A single surgeon retrospective cohort study

BACKGROUND

We present a comparative series to utilize minimally invasive endoscopic, total extraperitoneal laparoscopic (TEP-lap), and transabdominal preperitoneal robotic perforator (TAP-RAP) harvest of the deep inferior epigastric (DIE) vessels for autologous breast reconstruction (ABR) to mitigate donor site morbidity. We hypothesized that TEP-lap and TAP-RAP harvests of abdominal-based free flaps are safe techniques associated with decreased fascial incision when compared with the endoscopic harvest.

METHODS

We designed a retrospective cohort series of subjects with newly diagnosed breast cancer who presented for ABR using endoscopic (control), laparoscopic, or robotic assistance between September 2017 and April 2019. The primary outcome variables were flap success (i.e., absence of perioperative flap loss), fascial incision length, and intraoperative complications. Secondary variables included operating time, costs, and postoperative complications within 90 days (arterial thrombosis, venous congestion, bulge/hernia, and operative revision). Exclusion criteria included < 90 days follow-up.

RESULTS

In total 94, 38, and 3 subjects underwent endoscopic, TEP-lap, and TAP-RAP flap harvests. Mean lengths of fascial incisions for the endoscopic and laparoscopic cohorts were 4.5 ± 0.5 cm and 2.0 ± 0.6 cm (p < 0.0001), while incision length depended on the concurrent procedure in the robotic cohort. No subjects required conversion to an open harvest. There were no bleeding complications, intra-abdominal injuries, flap losses, or abdominal bulges/hernias noted in the TEP-lap and TAP-RAP cohorts.

CONCLUSION

Minimally invasive DIEP flap harvest may decrease fascial injury when compared with conventional open harvest. There are significant trade-offs among harvest methods. TEP-lap harvest may better balance the trade-off related to abdominal wall morbidity.

Partial DIEP flap loss in a patient with history of abdominal liposuction

Classically, history of prior abdominal liposuction has been considered a relative contraindication for breast reconstruction using deep inferior epigastric perforator (DIEP) flap. The rationale for this is based on the fact that liposuction can possibly damage perforating vessels, which could compromise flap survival. However, multiple recently published reports have shown that imaging using CT angiography or colour Duplex ultrasonography could be used to accurately assess the adequacy of the perforating vessels before DIEP flap harvest. This contraindication is currently being reconsidered in the scientific literature. We present a case of partial DIEP flap loss in a patient with history of abdominal liposuction that happened despite preoperative identification of adequate perforators using CT angiography and intraoperative clear evidence of patent anastomoses. This occurrence reopens in our view the question of whether DIEP flaps can be safely performed on patients with a history of abdominal liposuction, even in the presence of adequate perforators on regular CT angiography or Doppler ultrasonography. While abdominal liposuction may not injure perforating vessels, its detrimental effect on linking micro-vessels within the flap cannot be fully evaluated using CT Angiography. Therefore, the use of another imaging modality, such as the indocyanine green laser angiography, to assess perfusion before DIEP flap harvesting is performed and could be considered in patients with history of abdominal liposuction.

The influence of mastectomy and reconstruction on residual upper limb function in breast cancer survivors

PURPOSE

Breast cancer survivorship is common (90% of women survive 5 or more years), but many women are not able to return to full function and well-being after treatment due to functional limitations, persistent pain, and inability to perform daily activities. Since each surgical reconstructive option (e.g., autologous tissue flaps versus implants) can impact shoulder and arm function differently, it is important to understand how shoulder and upper limb strength, mobility, and function are influenced by the type of surgical intervention. Efforts can then focus on prehabiliation strategies to prevent the onset of limitations and on developing rehabilitation protocols that directly target shortcomings.

METHODS

The current paper presents a review summarizing how shoulder and upper limb function may be affected by surgical mastectomy and breast reconstruction.

RESULTS

Mastectomy and breast reconstruction with implants or autologous tissues present different functional outcomes for patients. Each surgical procedure is associated with unique sequelae derived from the tissues and procedures associated with each surgery. Characterizing the specific functional outcomes associated with each surgical approach will promote the development of targeted rehabilitation strategies that can be implemented into a multidisciplinary treatment planning pathway for breast cancer patients.

CONCLUSIONS

Surgical treatments for breast cancer, including mastectomy and breast reconstruction, can have negative effects. Focused efforts are needed to better understand treatment-specific effects so that targeted rehabilitation can be developed to improve patient function, QoL, and ability to return to work and life activities post-breast cancer.

Umbilical Ablation During Deep Inferior Epigastric Perforator Flap Harvest Decreases Donor Site Complications

BACKGROUND

Donor site complications are a significant source of morbidity for patients undergoing abdominal-based free flap breast reconstruction, but there is a paucity of data regarding minimizing these postoperative complications. We hypothesize that selective ablation of the umbilicus at the time of deep inferior epigastric perforator (DIEP) harvest decreases the incidence of umbilical and abdominal wall complications in high-risk patients.

METHODS

A retrospective review was performed of all patients (n = 117) who underwent DIEP harvest with concomitant umbilical ablation from 2010 to 2015. This cohort was paired with 117 patients who underwent DIEP harvest without umbilical ablation. Preoperative risk factors, intraoperative factors, and postoperative complications were compared.

RESULTS

The umbilical ablation group had significantly higher body mass index (30.9 vs 27.4 kg/m, P < 0.001), presence of umbilical scar (20.9% vs 5.3%, P < 0.001), umbilical hernia (82.9% vs 8.5% P < 0.001), ventral hernia (23.9% vs 1.7%, P < 0.001), and rectus diastasis (10.3% vs 2.6%, P = 0.016). There were no significant differences of smoking, diabetes mellitus, hypertension, prior abdominal surgery, or midline abdominal scar. The umbilical ablation group had a significantly lower rate of postoperative abdominal wound dehiscence and skin loss (11.1% vs 22.2%, P = 0.023) and overall donor site complications (24.8% vs 39.3%, P = 0.017). There was no significant difference in incidence of cellulitis, seroma, or abscess. Mean follow-up time was 1.8 years.

CONCLUSIONS

Selective umbilical ablation in high-risk patients at the time of abdominal flap harvest can result in significantly fewer donor site wound complications, even in the setting of increased risk factors for poor wound healing. This is likely due to avoidance of umbilical incisions and decreased upper abdominal skin undermining. We conclude that umbilical ablation is a viable option to minimize donor site complications, especially in high-risk patients.

Impact of Rectus Muscle Injury during Perforator Dissection on Functional Donor Morbidity after Deep Inferior Epigastric Perforator Flap Breast Reconstruction

This study aimed to assess the extent of rectus muscle damage in deep inferior epigastric perforator (DIEP) flap harvest and to evaluate its association with functional donor morbidity.

A systematic review of donor site aesthetic and complications after deep inferior epigastric perforator flap breast reconstruction

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.

Autologous Breast Reconstruction with Transverse Rectus Abdominis Musculocutaneous (TRAM) or Deep Inferior Epigastric Perforator (DIEP) Flaps: An Analysis of the 100 Most Cited Articles

Post-mastectomy autologous reconstruction with abdominal tissue has evolved over the past 4 decades and is a common reconstructive modality today. To gain more insight into this evolution, we performed an analysis of the 100 most commonly cited articles focusing on autologous breast reconstruction with transverse rectus abdominis musculocutaneous (TRAM) or deep inferior epigastric perforator (DIEP) flaps.

A review of the ISI Web of Knowledge database was performed. Only peer-reviewed articles in English were included for analysis. Articles were ranked by their total citations as well as citation density (citations divided by years since publication). The 100 most cited articles were analyzed by their bibliographic parameters.

The 100 most cited articles were published in 12 journals. The highest ranked plastic surgery journal published almost 2/3 of the articles. All articles were published within 23 years and marked the “rising age” of autologous breast reconstruction with TRAM and DIEP flaps. The focus of clinical research changed over this time period and ranged from innovations in surgical technique to analysis of clinical outcomes, comparative analyses with other reconstructive modalities, timing of reconstruction, and preoperative diagnostic workup, as well as cost-effectiveness analyses.

This literature review illustrates the dramatic change that has occurred subsequent to introduction of abdominal flaps for breast reconstruction. While the use of abdominal flaps has become widely accepted for breast reconstruction, many questions remain unanswered, thus highlighting the need for ongoing clinical investigation.

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

BACKGROUND

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

PATIENTS AND METHOD

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

RESULTS

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

CONCLUSION

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

Free tissue transfer with the free rectus abdominis flap in high-risk patients above 65 years: A retrospective cohort study

BACKGROUND

Though technically feasible, free tissue transfer carries the risk of perioperative morbidity and mortality in elderly patients. To minimize the operative treatment time and complication rates, we choose the rectus abdominis muscle (RAM) flap.

METHODS

Between 2012 and 2017, 34 patients (mean age: 74±7 years, range: 65-89 years) with comorbidities underwent defect reconstruction with a free RAM flap. Recipient-sites were: lower extremity (65%), trunk (18%), upper extremity (12%), and head and neck (6%).

RESULTS

The ASA status was 2 in 11 patients, 3 in 21 patients, and 4 in 2 patients. Twenty patients (59%) received additional vascular surgery. Three patients (9%) underwent simultaneous restoration of fractures. The mean operative time (OT) was 325±75 min. There was no total flap loss. Partial flap loss occurred in one patient (3%). The incidence of surgical and medical complications was 32% and 38%: 11 patients experienced a total of 22 surgical complications, of which 15 were major (requiring additional surgery) and 7 minor (conservative treatment). One patient died postoperatively because of progressive respiratory failure. Prolonged OT was highly associated with hematoma formation requiring re-operation (p = 0.01). ASA status was a significant predictor for postoperative critical care monitoring (p = 0.03). Reconstruction was successful in 31 out of 34 patients (91%) during a mean follow-up time of 17.7 ± 8.8 months (range: 2-51 months).

CONCLUSION

The free RAM flap has proven as a reliable and efficient tool in the armamentarium of reconstructive microvascular surgeons with some advantages in the treatment of multimorbid patients older than 65 years.

Preoperative and Postoperative Assessment of Rectus Abdominis Muscle Size and Function following DIEP Flap Surgery

BACKGROUND

Prospective evaluation of rectus abdominis muscle function after deep inferior epigastric artery perforator (DIEP) flap breast reconstruction is limited. Elimination of muscle harvest with this procedure is theoretically associated with preservation of rectus abdominis function and minimization of abdominal wall morbidity. In this study, the authors evaluate the change in rectus abdominis muscle size and function after DIEP flap surgery.

METHODS

Patients undergoing unilateral DIEP flap surgery were recruited prospectively. Using computed tomography, the change in preoperative to postoperative rectus abdominis muscle size was compared between the operative side rectus abdominis muscle and the contralateral, nonoperative control rectus abdominis. Postoperative muscle integrity and contractility were evaluated using ultrasound by comparing the change in rectus abdominis muscle dimensions between contractile and relaxed states. The BREAST-Q was used to score patients' subjective satisfaction. Clinical and radiographic hernia rates were also calculated.

RESULTS

Analysis of 26 paired rectus abdominis muscles revealed no significant change in muscle size from preoperative to postoperative values. Furthermore, dimensional change from contractile to relaxed states postoperatively was similar for paired operative and nonoperative rectus abdominis muscles. BREAST-Q scores indicated a high degree of satisfaction in abdominal well-being, breast satisfaction, and surgical experience domains. There were no clinical or radiographic abdominal wall hernias noted.

CONCLUSIONS

The DIEP flap is an effective surgical procedure with minimal abdominal wall morbidity that is associated with no measurable loss in rectus abdominis size and contractile function postoperatively. Patients are highly satisfied with their abdominal function postoperatively using this technique.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

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