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

A DIEP Dive into Patient Risk Factors for Hernia and Bulge Development: A Meta-regression

BACKGROUND

 This meta-regression aims to investigate risk factors for abdominal hernia and bulge in patients undergoing deep inferior epigastric perforator (DIEP) flaps and the effect of prophylactic mesh placement on postoperative complications.

METHODS

 A systematic search was conducted in July of 2022 in alignment with the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Seventy-four studies published between 2000 and 2022 met the inclusion criteria. Sixty-four studies were included in the analysis for bulge and 71 studies were included in the analysis for hernia. Meta-regressions were run on the proportion of patients experiencing hernia or bulge to assess for patient risk factors and the role of prophylactic mesh placement. Proportions were transformed using the Freeman-Tukey double arcsine method.

RESULTS

 The average rates of hernia and bulge after DIEP flaps were found to be 0.18% and 1.26%, respectively. Increased age (β = 0.0059, p = 0.0117), prior abdominal surgery (β = 0.0008, p = 0.046), and pregnancy history (β = -0.0015, p = 0.0001) were significantly associated with hernia. Active smoking (β = 0.0032, p = 0.0262) and pregnancy history (β = 0.0019, p < 0.0001) were significantly associated with bulge. Neither the perforator vessel laterality nor the number of perforator vessels harvested had any association with hernia or bulge. Prophylactic mesh placement was not associated with hernia or bulge.

CONCLUSION

 Understanding the comorbidities associated with hernia or bulge following DIEP flap breast reconstruction, such as advanced age, prior abdominal surgery, pregnancy history, and active smoking status, allows surgeons to proactively identify and educate high-risk patients. Future studies may further explore whether prophylactic mesh placement offers patients any benefit.

Approach to DIEP Flap Pedicle Dissection via a Midline Fascial Incision

In this article, our technique for deep inferior epigastric pedicle dissection utilizing a midline fascial incision is described. Approaching these vessels via a midline facial incision provides facile access to the retrorectus space bilaterally, utilizes a dissection plane that facilitates preservation of nerve and muscle fibers, and allows for both efficient and ergonomic pedicle dissection. This method is safe and easily reproducible and may reduce abdominal donor site morbidity in deep inferior epigastric perforator flap breast reconstruction.

Perforator Dissection Porcine Abdominal Model: A Novel Simulator to Improve Microsurgical Training

BACKGROUND

 Perforator dissection and flap elevation are routinely performed for microsurgical reconstruction; however, there is a steep learning curve to mastering these technical skills. Though live porcine models have been utilized as microsurgical training models, significant drawbacks limit their use. We recently developed a latex-perfused, nonliving, porcine abdomen perforator dissection simulation and described its anatomic similarity to the human deep inferior epigastric artery flap. The purpose was to assess the change in resident confidence in performing key operative steps of flap elevation and perforator dissection and obtain feedback on model realism and utility.

METHODS

 Seventeen plastic and reconstructive surgery resident physicians (postgraduate years 1-6) at a single institution participated in a perforator dissection session utilizing the simulation model. Each resident completed pre- and postactivity surveys to assess interval change in confidence in operating. The postactivity survey also asked residents to answer questions regarding their perception of the model's anatomic and surgical realism and utility in microsurgical training.

RESULTS

 Following a practice session using the latex-perfused, nonliving porcine abdomen, resident confidence was significantly increased in performing all key operative steps and the procedure overall (p = 0.001). All residents (n = 17, 100%) believed the model would improve "trainees' ability to perform perforator dissection in the operating room." Perforator, fascial, and pedicle anatomy were reported to be "Very" similar to human anatomy, with a median Likert score (MLS) of 4. Additionally, six out of the eight surgical steps were noted to be "Very" realistic, with only "Flap Design" and "Fascial Closure" found to be "Moderately" realistic with an MLS of 3.

CONCLUSION

 The latex-infused porcine abdominal model is a novel, realistic simulation for microsurgical trainee perforator dissection practice. This model offers a suitable substitute for perforator dissection practice, as its implementation within a microsurgery training course improves resident comfort and confidence.

Is There a Difference in Abdominal Wall Muscle Strength, Endurance, and Motor Control Following Bilateral DIEP and TRAM Flaps for Breast Reconstruction?

Background

Abdominal donor site complications in bilateral pedicled transverse rectus abdominis muscle (TRAM) have been a concern when compared with bilateral deep inferior epigastric perforator (DIEP) flap breast reconstruction. This study aimed to assess the strength, endurance, and motor control in patients undergoing DIEP and TRAM flaps.

Methods

A prospective, cohort study was performed at a single institution including patients who underwent pedicled TRAM and DIEP flap reconstruction after mastectomy from August 2017 to August 2018. Patients underwent pre- and postoperative testing involving rectus abdominis, prone plank, side bridge, and trunk flexor tests. Descriptive analyses and multivariate linear regressions were performed.

Results

The final analysis included a total of 9 patients, 4 of whom underwent TRAM flap reconstruction while 5 underwent DIEP flap reconstruction. The tests were not statistically significant between the TRAM versus DIEP groups, including rectus abdominis mean time decrease (0.25 vs 0.60 sec, P = .51), prone plank time increase (1.38 vs 1.38 sec, P = .51), right side bridge time increase (7.54 sec vs 32.15 sec, P = 1.00), left side bridge time increase (2.14 vs 44.5 sec, P = .37), and trunk flexor time decrease (4.68 vs 1.68 sec, P = .44). Overall complications were similar between the 2 groups.

Conclusions

No significant difference in abdominal donor site morbidity was found when comparing the 2 groups. This article provides a point of conversation with patients when discussing available reconstruction options.

The Role of Measurement of Pedicle Length for DIEP Flap Transferring in Breast Reconstruction: A Single-Center, Open-Label, Randomized Controlled Trial

BACKGROUND

Intraoperative venous congestion is a main complication in deep inferior epigastric artery perforator (DIEP) flap for breast reconstruction. We present a pedicle measuring technique to precisely predict the length of pedicle needed in DIEP free flap, to improve the outcome, and to reduce the risk of donor site morbidity and complications.

MATERIALS AND METHODS

A single-center, open-label, prospective, randomized study was carried out to access efficacy and safety of a pedicle measuring technique in 389 patients. Each patient received a delayed breast reconstruction using free unipedicled DIEP flap, and internal mammary vessels were chosen as recipient vessels. During the surgery, the conventional DIEP flap technique was used in the control group, in which the course of the pedicle was fully dissected. In the measuring group, the flap in setting way was decided preoperatively, the distance (A) between the internal mammary vessels (a) and the point of DIEP perforator into the subcutaneous tissue (b) was measured, and then the length (B) of the perforator (c) and the main trunk (d) is measured and dissected to achieve 1 cm longer than A.

RESULTS

There are 180 and 209 patients enrolled in the control and measuring group, respectively. Venous congestion occurred in 15 patients (8.3%) in the control group, and 1 patient (0.5%) in the measuring group ( P < 0.001). All the 16 patients were found venous thrombosis. Then successful free flap salvage surgeries were performed in 10 patients. Six patients (3.3%) had total flap necrosis due to recurrent venous thromboembolisms. Fat necrosis occurred in 16 patients (8.9%) in the control group, and 5 patients (2.4%) in the measuring group ( P = 0.006). Partial flap necrosis was found in 12 patients (6.7%) in the control group, and in 3 patients (1.4%) in the measuring group ( P = 0.008). Total flap necrosis occurred in 6 patients (3.3%) in the control group, but no (0%) patient in the measuring group ( P = 0.009).

CONCLUSIONS

Measurement of pedicle length for DIEP flap transferring in breast reconstruction is a reliable technique that could secure the DIEP free flap, reduce operative invasiveness, and lower the risk of complications considerably.

A New CT Analysis of Abdominal Wall after DIEP Flap Harvesting

The abdominal microsurgical flap based on the deep inferior epigastric artery perforator (DIEP) flap has become the most popular option worldwide for autologous breast reconstruction. Several authors have investigated the results of reconstructed breasts, but the literature lacks systematic reviews exploring the donor site of the abdominal wall. To fulfil our aims, a new diagnostic muscle imaging analysis was designed and implemented. This study focused on rectus abdominal muscle morphology and function in a single series of 12 consecutive patients analysed before and after breast reconstruction with a microsurgical DIEP flap. Patients were divided into two groups, namely, “ipsilateral reconstruction” and “contralateral reconstruction”, depending on the side of the flap harvest and breast reconstruction, then evaluated by computed tomography (CT) scans scheduled for tumor staging, and clinically examined by a physiatrist. Numerous alterations in muscle physiology were observed due to surgical dissection of perforator vessels, and rectus muscle distress without functional impairment was a common result. Postoperatively, patients undergoing “contralateral reconstruction” appeared to exhibit fewer rectus muscle alterations. Overall, only three patients were impacted by a long-term deterioration in their quality of life. On the basis of the newly developed and implemented diagnostic approach, we concluded that DIEP microsurgical breast reconstruction is a safe procedure without major complications at the donor site, even if long-term alterations of the rectus muscle are a common finding.

Use of a combined SIEA and SCIP based double pedicled abdominal flap for breast reconstruction

BACKGROUND

Recently, the deep inferior epigastric perforator (DIEP) flap has become the gold standard for breast reconstruction, but it has some drawbacks such as abdominal bulging and hernia. To overcome these disadvantages, the superficial inferior epigastric artery perforator (SIEA) flap is used as an alternative option, but it has another problem, namely limited vascular territory and risk of vascular thrombosis. To solve these problems, we introduced our new technique, a combined SIEA and superficial circumflex iliac artery perforator (SCIP) based double pedicled abdominal flap. In this report, we present our experience of using this technique.

METHODS

The SIEA and SCIP based double pedicled abdominal flap was used in five patients who wanted to have unilateral breast reconstruction after a mastectomy due to breast cancer. The average age was 48.2 (range 38-56) years, and the average BMI was 24.4 (range 19.2-31.4). The SIEA and SCIP based double pedicled abdominal flap was designed as a modified DIEP flap, and all flaps were placed in the vertical setting. The flap pedicles had two different vascular supplies, SIEA and SCIA, and the drainage systems, SIEV and SCIV, anastomosed to the internal mammary artery and vein in all cases.

RESULTS

The harvested SIEA and SCIP based double pedicled abdominal flaps were a median volume of 925 g (range 452-1570 g) and average size of 491 cm² (range 440-611 cm² ). The average reconstructive time was 7:41 (range 6:31-9:17). In four out of the five cases, the SIEA and SCIA joined together to make a common pedicle artery trunk, and its average size was 1.08 mm. Four out of the five cases had a wide vascular territory crossing the abdominal midline as shown by ICG angiography. One case showed ICG fluorescence for the hemi-side of the abdominal flap. Postoperative course was uneventful, and there were no major perioperative complications, which need extra surgical procedures. Follow-up period averaged 273 days (range 194-312 days).

CONCLUSION

The SIEA and SCIP based double pedicled abdominal flap showed viable flap territory across the midline in all cases. The SIEA and SCIP based double pedicled abdominal flap might be another ideal option for breast reconstruction, when appropriate SIEA and SCIA pedicles are identified, and an adequate ICG fluorescence is obtained for the size of flap needed.

Influence of closed incision negative-pressure therapy on abdominal donor-site morbidity in microsurgical breast reconstruction

INTRODUCTION

Closed incision negative-pressure therapy (CINPT) has been shown to shorten the time to heal in post-bariatric abdominoplasty and to lower seroma rates in cosmetic abdominoplasty. The objective of this study was to assess the effect of CINPT on donor-site morbidity following abdominal-based free-flap breast reconstruction.

PATIENTS AND METHODS

We reviewed medical records from 225 women who had undergone 300 microsurgical free-flap breast reconstructions from the abdomen from November 1, 2007 to March 31, 2019. Patients were grouped according to wound therapy, including 127 patients in the standard of care group and 98 patients in the CINPT group. Primary outcomes were minor (non-operative) and major (operative) surgical site complications. Secondary outcomes were time to drain removal, in-hospital length, and scar quality.

RESULTS

Analysis of patient demographics showed an equal distribution with regard to the age, smoking status, prevalence of diabetes mellitus, preoperative chemotherapy, and previous abdominal surgery in both groups. Significantly more patients with obesity (29.6 vs. 15.8%; p = .01) and bilateral breast reconstruction (40.8 vs. 27.6%; p = .04) were included in the CINPT group. Compared to standard of care, the CINPT group had a lower incidence of major surgical site complications (26.0 vs. 11.2%; p = .001). There was no difference in minor surgical site complications and secondary outcomes between groups.

CONCLUSION

The CINPT represents a reliable tool to reduce surgical site complications on the abdominal donor-site in abdominal-based free-flap breast reconstruction.