Duplex ultrasound-based step-by-step perforator mapping by a microsurgeon for DIEP flap planning: A prospective case series.

PURPOSE: Studies have suggested several factors that affect free flap fat necrosis and abdominal morbidity after DIEP flap breast reconstruction. We aimed, by conducting the most inclusive and current multivariate analysis of these factors to date, to clarify how patient specific perforator selection can affect fat necrosis and abdominal morbidity, thus guiding future operative decision-making. METHODS: Retrospective review of a prospectively maintained, 866 free-flap database was performed for patients undergoing breast reconstruction at one institution from 2010–2016. 29 potential predictors, including patient demographic factors and intraoperative parameters, were included in a multivariate analysis for outcomes of fat necrosis, abdominal wounds, and abdominal bulge or hernia. These results were reported as Odds Ratios (OR) with 95% Confidence Intervals. Univariate analyses were utilized to confirm that potentially confounding pre-surgical and intraoperative factors amongst each of the three primary outcome variables were sufficiently equivalent. Any wound requiring local wound care after 2 weeks was characterized as a minor abdominal wound, whereas major abdominal wounds were defined as wounds requiring return to the operating room. RESULTS: 409 total DIEAP flaps were included with an average 18.5-month follow-up: 14.4% had fat necrosis, 21.2% had a minor or major abdominal wound, and 6% had an abdominal bulge or hernia. Analysis showed increased odds of fat necrosis with increasing flap weight (OR 1.002 per 1g increase, p<.001), and earlier year of surgery (OR 2.324 for 2010–2013 vs. 2014–2016, p=.02), and decreased odds of fat necrosis with lateral or both-row perforators vs. medial row (OR.303, .0229, p-value=.0013), and neoadjuvant chemotherapy (OR.384, p=.016). Perforator flow rate/caliber and number of perforators did not affect fat necrosis. However, upon subgroup analysis on flaps with fat necrosis, we found that there was a significant difference in weight between single perforator flaps and multi-perforator flaps (789g vs. 983g respectively, p= .048). There was an increased odds of having abdominal wounds with smoking (OR 1.869, p=.02), hypertension (OR 1.720, p=.04), and increasing flap weight (OR 1.001 per 1g increase, p<.01). BMI was not a significant factor for abdominal wounds when controlled by flap weight in the multivariate analysis. Increased odds of abdominal bulge/hernia were seen with a return to the OR same hospital stay (OR 5.922, p<.01), and with lateral/both row perforators vs. medial row (OR 3.01, p=.058). CONCLUSIONS: Our analysis of DIEP flaps shows surgeon experience reduced the odds of fat necrosis, while heavier flap weights increased these odds. Moreover, adding lateral row perforators may decrease fat necrosis at the potential cost of increasing abdominal bulges. While perforator number was not a significant predictor of fat necrosis in the multivariate analysis, the subgroup analysis may indicate that there is a higher allowable threshold of flap weight before fat necrosis occurs with multi-perforator versus single perforator DIEP flaps. A.S. Hembd: None. M. Cho: None. C. Venutolo: None. S. Teotia: None. N. Haddock: None.

BackgroundA common complication after a DIEP flap reconstruction is the occurrence of fat necrosis due to inadequate flap perfusion zones. Intraoperative identification of ischemic zones in the DIEP flap could be optimized using indocyanine green near-infrared fluorescence angiography (ICG-NIR-FA). This randomized controlled trial aims to determine whether intraoperative ICG-NIR-FA for the assessment of DIEP flap perfusion decreases the occurrence of fat necrosis. Design/methodsThis article describes the protocol of a Dutch multicenter randomized controlled clinical trial: the FAFI-trial. Females who are electively scheduled for autologous breast reconstruction using DIEP or muscle-sparing transverse rectus abdominis muscle (msTRAM) flaps are included. A total of 280 patients will be included in a 1:1 ratio between both study arms. In the intervention arm, the intraoperative assessment of flap perfusion will be based on both regular clinical parameters and ICG-NIR-FA. The control arm consists of flap perfusion evaluation only through the regular clinical parameters, while ICG-NIR-FA images are obtained during surgery for which the surgeon is blinded. The main study endpoint is the difference in percentage of clinically relevant fat necrosis between both study arms, evaluated two weeks and three months after reconstruction. ConclusionThe FAFI-trial, a Dutch multicenter randomized controlled clinical trial, aims to investigate the clinical added value of intraoperative use of standardized ICG-NIR-FA for assessment of DIEP/msTRAM flap perfusion in the reduction of fat necrosis. Clinical trial registration numberNCT05507710; NL 68623.058.18.

Introduction Deep inferior epigastric perforator (DIEP) flaps are established as the preferred flap for breast reconstruction. Venous congestion is the most common vascular complication that can lead to flap failure and fat necrosis. While limited studies have attempted to assess use of superdrainage using superficial inferior epigastric vein (SIEV) in DIEP flaps, they were inconclusive with small cohort sizes. Aims The primary aims of this study were to assess association between use of SIEV in DIEP flaps and reconstructive outcomes based on degree of venous congestion as well as number of graft failures, fat necrotic flaps and post-operative visits. The secondary aims were to analyse the intra-operative time to harvest SIEV and impact of costs to the NHS. Methodology 2154 patients undergoing DIEP flap reconstruction from March 2010 to June 2022 were restrospectively analyzed. Demographic data, chemo/radiotherapy status, and technique/flap details were procured. Outcome endpoints were evaluated based on occurrence of post-operative venous congestion, total and partial flap loss, fat necrosis, and operative time. Sub-set analysis of demographics was done to assess impact on outcomes. Results SIEV use was observed in 216 cases. Total flap loss was observed in 2.31% and partial flap loss in 6.48%. Fat necrosis was observed in 3.24% and post-operative venous congestion in 0.92%. Operative time was observed as 376 ± 48 minutes. Conclusion Although there was slightly increased operative time for SIEV harvest, superdrainage considerably reduced venous congestion, flap compromise, and related complications indicating improved overall cost to the NHS.

The quality of reporting in randomised controlled trials in plastic surgery

Autologous breast reconstruction is highly regarded in reconstructive surgery after mastectomy. DIEP flap reconstruction represents the gold standard for autologous breast reconstruction. The major advantages of DIEP flap reconstruction are its adequate volume, large vascular caliber and pedicle length. Despite reliable anatomy, there are procedures where the plastic surgeon's creativity is required, not only to shape the new breast, but also to overcome microsurgical challenges. An important tool in these cases is the superficial epigastric vein (SIEV). 150 DIEP flap procedures performed between 2018 and 2021 were retrospectively evaluated for SIEV use. Intraoperative and postoperative data were analyzed. Rate of anastomosis revision, total and partial flap loss, fat necrosis and donor site complications were evaluated. In a total of 150 breast reconstructions with a DIEP flap performed in our clinic, the SIEV was used in 5 cases. The indication for using the SIEV was to improve the venous drainage of the flap or as a graft to reconstruct the main artery perforator. Among the 5 cases, no flap loss occurred. Use of the SIEV is an excellent method to expand the microsurgical options in breast reconstruction with DIEP flap surgery. It provides a safe and reliable procedure to improve venous outflow in cases of inadequate outflow from the deep venous system. The SIEV could also provide a very good option for fast and reliable application as an interposition device in case of arterial complications.

This study aims to determine the relationship between race and ischemic complications in women undergoing breast reconstruction with pedicled TRAM (pTRAM) and perforator flaps (DIEP). A retrospective, cross-sectional study of women who underwent breast reconstruction utilizing either pTRAM or DIEP flaps from March 1, 2002 to September 1, 2012 was performed. Clinical and demographic variables, including race and ischemic complications (mastectomy flap necrosis, fat necrosis, partial abdominal flap necrosis, vascular compromise requiring reoperation), were examined. Fat necrosis was graded using a previously established scale (grade I = radiologically visible, II = palpable, III = palpable and visible, IV = symptomatic). Over the 10-year study period, adequate follow-up was available for 138 women (94 Caucasian, 36 African American) who underwent pTRAM or DIEP. Fat necrosis occurred more frequently in the pTRAM group (53.5% vs. 17.4%, P < 0.001). There was no statistically significant difference in partial flap necrosis or mastectomy flap necrosis between the 2 groups. The DIEP group had a higher rate of vascular compromise requiring reoperation (13% vs. 0, P = 0.003). In the pTRAM group, there was a higher rate of fat necrosis (77% vs. 45.6%, P < 0.001) and grade IV fat necrosis in African Americans (42.8% vs. 9.5%, P = 0.005). Rates of other ischemic complications were comparable between the 2 racial groups. In the DIEP group, ischemic complications were comparable between the 2 racial groups. After stratifying by flap type and race, we saw no differences in mastectomy flap necrosis (P = 0.0182). African Americans undergoing pTRAM flap are at higher risk for grade IV fat necrosis but not mastectomy flap necrosis or partial flap necrosis. This may be due to difficulty using physical examination to judge the vascular status of a pedicle flap that is known to undergo significant changes in vascular physiology following transfer. Intraoperative assessment of perfusion using new technologies may be useful in these higher risk patients.

Background: Venous congestion is a major contributor to complications in DIEP flap breast reconstruction. Beyond superficial venous dominance, the presence or absence of anatomical connections between the superficial and deep venous systems may influence drainage physiology. This study investigates how preoperative CTA and targeted superdrainage impact outcomes over a 25-year period. Patients and Methods: A retrospective analysis was conducted on 208 DIEP flaps performed from 2000 to 2024 at a single center. From 2006, computed tomographic angiography (CTA) was routinely used to evaluate venous anatomy, focusing on the presence, trajectory, and connection of the superficial inferior epigastric vein (SIEV) with the deep system. Superdrainage was performed when superficial venous dominance was evident or drainage was judged insufficient intraoperatively. Primary outcomes included venous congestion, partial necrosis, and reoperations; secondary outcomes included hospital stay and safety of superdrainage. Results: Venous complications decreased significantly after CTA implementation (37.5% vs. 8.0%; p < 0.001). Superdrainage was performed in 40.9% of post-CTA cases, with 90% preoperatively planned based on CTA findings. No complications were associated with second venous anastomosis. Flap outcomes correlated not with perforator number or flap size but with venous drainage physiology. Mean hospital stay was shorter post-CTA (6 vs. 9 days; p < 0.001). Conclusions: Evaluating the anatomical connection between superficial and deep venous systems via CTA enhances venous planning and allows for safer, physiology-driven decisions. In the absence of such connections, intraoperative evaluation remains essential. Drainage physiology—rather than anatomical metrics alone—should guide surgical strategy in DIEP flap reconstruction.

Background:The aim of this study was to evaluate the association between flap harvest technique and occurrence of abdominal bulging.Methods:A retrospective analysis of 159 patients undergoing DIEP flap breast reconstruction between 2014 and 2021 in the University Medical Center Utrecht was conducted. Outcomes measured were preoperative rectus diastasis, flap weight, laterality of flap harvest (unilateral or bilateral), timing of the harvest (immediate or delayed), number of perforators harvested (single or multiple), and location of the harvested perforator (medial, lateral, or both).Results:In 159 patients, 244 DIEP flaps were performed, 16 of these donor-sites (6.6%) developed a clinically evident abdominal bulge. When preoperative rectus abdominis diastasis was found (n = 97), postoperative bulging occurred significantly more often (P < 0.01). Patients in whom the medial perforator artery was harvested for reconstruction (n = 114) showed less abdominal bulging than patients in whom the lateral (n = 92) was harvested (P = 0.02). Using single versus multiple perforators for the DIEP flap, bilateral versus unilateral reconstruction or timing of the operation showed no significant difference in outcome of bulging (P = 1.00, P = 0.78, P = 0.59, respectively).Conclusions:The incidence of bulging in our study cohort is comparable to the literature. Harvesting the medial perforator artery for the DIEP flap showed less abdominal bulging than using the lateral perforator artery in a DIEP flap breast reconstruction. Also, preoperative rectus diastasis was found to be an important risk factor for the occurrence of bulging.

Background:Compromised perfusion in autologous breast reconstruction results in fat necrosis and flap loss. Increased flap weight with fewer perforator vessels may exacerbate imbalances in flap perfusion. We studied deep inferior epigastric perforator (DIEP) and muscle-sparing transverse rectus abdominis myocutaneous (MS-TRAM) flaps to assess this concept.Methods:Data from patients who underwent reconstruction with DIEP and/or MS-TRAM flaps between January 1, 2010 and December 31, 2011 (n = 123) were retrospectively reviewed. Patient demographics, comorbidities, intraoperative parameters, and postoperative outcomes were collected, including flap fat necrosis and donor/recipient site complications. Logistic regression analysis was used to examine effects of flap weight and perforator number on breast flap fat necrosis.Results:One hundred twenty-three patients who underwent 179 total flap reconstructions (166 DIEP, 13 MS-TRAM) were included. Mean flap weight was 658 ± 289 g; 132 (73.7%) were single perforator flaps. Thirteen flaps (7.5%) developed fat necrosis. African American patients had increased odds of fat necrosis (odds ratio, 11.58; P < 0.001). Odds of developing fat necrosis significantly increased with flap weight (odds ratio, 1.5 per 100 g increase; P < 0.001). In single perforator flaps weighing more than 1000 g, six (42.9%) developed fat necrosis, compared to 14.3% of large multiple perforator flaps.Conclusions:Flaps with increasing weight have increased risk of fat necrosis. These data suggest that inclusion of more than 1 perforator may decrease odds of fat necrosis in large flaps. Perforator flap breast reconstruction can be performed safely; however, considerations concerning race, body mass index, staging with tissue expanders, perforator number, and flap weight may optimize outcomes.

One-stage DIEP flap breast reconstruction: Algorithm for immediate contralateral symmetrization.

Soft-tissue defects of the limbs with exposed bone or orthopedic hardware remain a major reconstructive challenge, particularly in patients in whom free tissue transfer is not feasible. The keystone perforator island flap (KPIF) provides a simple, reliable, and resource-efficient local flap option based on perforator preservation and tension redistribution, and can be safely performed under local anesthesia. This prospective clinical study included 12 patients (8 men and 4 women) with small-to moderate-sized limb soft-tissue defects with exposed bone or orthopedic hardware who underwent reconstruction using the KPIF between January 2021 and June 2025. Preoperative perforator mapping was performed using a handheld Doppler, and all dominant perforators were preserved during flap elevation. Wound beds were prepared using preoperative negative pressure wound therapy (NPWT) for contaminated or poorly granulating wounds. KPIF reconstruction was performed predominantly under epinephrine-free local anesthesia with or without tumescent infiltration, following a standardized surgical protocol. Complete flap survival was achieved in all patients with small defects (7/7), whereas one patient in the moderate defect group (1/5) developed minor distal partial flap necrosis that healed conservatively without additional surgical intervention. Most procedures were performed under epinephrine-free local anesthesia, with no need for conversion to general anesthesia and no anesthesia-related complications. No total flap loss, postoperative infection, or donor-site morbidity was observed. The mean operative time was 45 min and all donor sites were closed primarily. During a mean follow-up of 6 months, all patients achieved stable soft-tissue coverage with favorable patient-reported functional and aesthetic outcomes (mean patient-reported outcome measures-visual analog scale (PROM-VAS): 8.6 and 8.4 for small defects; 7.9 and 7.8 for moderate defects, respectively). KPIF provides reliable coverage for small limb defects with exposed bone or hardware, and can be safely and effectively performed under local anesthesia, offering a practical alternative to microsurgical reconstruction in appropriately selected patients.

Numerous minimally invasive deep inferior epigastric perforator flap (MI-DIEP) techniques have been described in the literature to reduce donor site morbidities. This systematic review aimed to summarize existing MI-DIEP techniques and postoperative outcomes relative to conventional harvest (cDIEP). A systematic review was conducted following Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines to include articles with novel DIEP harvesting techniques. Studies without perioperative information were excluded. Chi-square and Fisher's exact test were used to compare complication rates (partial flap loss, total flap loss, hernia or bulge, and fat necrosis) in MI-DIEP with cDIEP. Joanna Briggs Institute critical appraisal tool was used for bias assessment. A total of 978 patients underwent 1,272 MI-DIEP flap harvests across 17 studies. Techniques included robotic DIEP (rDIEP; n = 97), abdominal perforator exchange (APEX; n = 158), laparoscopic (n = 39), endoscopic (n = 94), two-staged delayed DIEP (n = 135), short fasciotomy (n = 124), short pedicle (n = 26), vascular pedicle measuring (n = 209), and microfascial incision (n = 81). No significant differences were found between endoscopic, laparoscopic, and robotic approaches compared with cDIEP. However, the short pedicle technique had higher partial flap loss (8.82% vs. 1.98%, p = 0.04), while APEX and vascular pedicle measuring techniques had lower fat necrosis rates (1.99% and 0.48% vs. 5.81%, p = 0.04 and 0.004 respectively). Short fasciotomy was associated with higher fat necrosis (12.9% vs. 5.8%, p = 0.004) and longer hospital stay (p = 0.005). Robotic, laparoscopic, endoscopic, two-staged, and APEX techniques were associated with shorter hospital stays, and rDIEP was linked to reduced postoperative day 1 pain (p < 0.001). MI-DIEP techniques demonstrate comparable complication rates to cDIEP, with certain methods offering benefits such as reduced fat necrosis, shorter hospital stays, and less postoperative pain.

Background Autologous breast reconstruction with deep inferior epigastric perforator (DIEP) flap and transversus rectus abdominis myocutaneous (TRAM) flap require precise preoperative planning. Our aim was to perform morphometric analysis of deep inferior epigastric artery (DIEA) and its perforators through CT-Angiography (CTA) during preoperative planning. Methods A prospective single center, single surgeon study of CTA of patients after mastectomy, undergoing DIEP or TRAM flap breast reconstruction from 2022 till 2024. Patients CTA images were analyzed for DIEA, DIEP and abdominal wall anatomy. Findings were correlated with rate of postoperative partial flap necrosis and total flap loss. Statistical analysis was performed by unpaired t test (two-tailed), Fisher´s exact test and Pearson correlation coefficient. Results CTA imaging was analyzed in 16 patients (100 perforators). Average number of lateral and medial row perforators per side was 1.39 ± 0.5 and 1.78 ± 0.8 (p &lt; 0.05), respectively. The mean diameter of dominant perforators was 0.85 ± 0.16 mm. The vertical and horizontal distance of dominant perforators from the umbilicus was on average 26.42 ± 18.2 mm and 35.4 ± 18.31 mm, respectively. Larger horizontal distance from the umbilicus correlated with lower rate of partial flap necrosis and total flap loss (p &lt; 0.05). Conclusion We found significant difference in number of medial and lateral perforators of DIEA. Horizontal position of the dominant perforator could have a sigificant impact on blood supply of the flap. Laterally positioned perforators are favored to minimize the risk of flap necrosis, however, in case where a larger reconstructed breast volume is required, we opt for medial row perforators with broader perfusion territory.

Leaving the perfusion zones? Individualized flap design in 100 free DIEP and ms-TRAM flaps for autologous breast reconstruction using indocyanine green angiography

BackgroundImplants and DIEP flaps have different outcomes regarding postoperative breast sensation. When compared to the preoperative healthy breast, implant-based breast reconstruction (IBBR) negatively influences postoperative breast sensation. However, it is currently unknown whether a prior IBBR also influences postoperative sensation of a replacing DIEP flap. The goal of this cohort study is to evaluate the influence of an IBBR on the postoperative sensation of a replacing DIEP flap.MethodsWomen were included if they received a DIEP flap reconstruction after mastectomy, with or without prior tissue expander (TE) and/or definitive breast implant. Sensation was measured at four intervals in 9 areas of the breast with Semmes–Weinstein monofilaments: T0 (preoperative, implant/no reconstruction), T1 (2–7 months postoperative, DIEP), T2 (± 12 months postoperative, DIEP), Tmax (maximum follow-up, DIEP). Linear mixed-effects models were used to investigate the relationship between an implant/TE prior to the DIEP flap and recovery of breast sensation.Results142 women comprising 206 breasts were included. 48 (23.3%) breasts did, and 158 (76.7%) breasts did not have a TE/IBBR prior to their DIEP. No statistically significant or clinically relevant relationships were found between a prior implant/TE and recovery of DIEP flap breast sensation for the flap skin, native skin, or total breast skin at T1, T2, or Tmax. There were also no relationships found after adjustment for the confounders radiation therapy, BMI, diabetes, age, flap weight, follow-up, and nerve coaptation.ConclusionsAn implant/TE prior to a DIEP flap does not influence the recovery of postoperative breast sensation of the DIEP flap.