Bipedicled Deep Inferior Epigastric Perforator Research Articles

Creating a context for recipient vessel selection in deep inferior epigastric perforator flap breast reconstruction

In autologous tissue breast reconstruction, recipient vessels are important for artery perfusion and venous drainage to ensure free flap survival. There are insufficient clinical outcomes to select efficient recipient vessels in bi-pedicled deep inferior epigastric perforator (DIEP) flap reconstruction. We presented a retrospective observational series of 108 patients regarding the diameter, anastomosis time, and re-anastomosis rate in internal mammary (IM), circumflex scapular (CS), thoracodorsal (TD), thoracoacromial (TA), lateral thoracic (LT), and internal mammary perforator (IMP) vessels of bi-pedicled DIEP flaps for breast reconstruction after mastectomy. The outcomes were the vessel re-anastomosis rate, flap failure rate, vessel anastomosis time, and complications. Data were gleaned from the chi-square test, Fisher's test, and analysis of variance using Scheffe's test as a post hoc analysis. The level of significance was p<0.05. There were no significant differences in the diameters of the artery, first vein, and second vein across the recipient vessels (p>0.05). However, the anastomosis time was longer in IM and TA than in CS, TD, and LT (p<0.001). Also, there were no significant differences for re-anastomosis, flap necrosis, and fat necrosis among different recipient vessels (p>0.05). Because of the altered mastectomy incisions, this study provides complete anatomical vascular properties and suggests that altering recipient vessel selection for bi-pedicled DIEP flaps can shorten anastomosis time and better conceal scars.

O030 DIEP flap reconstruction- a single-centre comparison of unipedicled and bipedicled DIEP flaps

Abstract Introduction The deep inferior epigastric perforator (DIEP) flap is the gold standard for autologous breast reconstruction. One or two pedicles may be used. Our study is the first to compare unipedicled vs bipedicled DIEP flaps on donor site morbidity and breast outcomes in the same set of patients. Methods A retrospective cohort study comparing outcomes of DIEP flaps between 2019–2022 at our hospital. Results There were 98 patients, categorised differently based on breast or donor site. The three breast groups were unilateral unipedicled (N=52), bilateral unipedicled (N=15) and unilateral, bipedicled (N=31) and donor site groups were, unipedicled (N=52) and bipedicled (N=46, bilateral unipedicled and unilateral bipedicled). Bipedicled DIEPs had 1.15 times greater odds of a donor site complication than unipedicled DIEPs (95% CI 0.52, 2.55). Adjusting for operative time which was longer in bipedicled DIEPS (p&amp;lt;0.001), odds ratio decreased and there was a lower probability of developing a donor site complication for bipedicled (OR 0.84, 95% CI 0.31, 2.29). Odds of developing a breast complication were not significantly different between groups. Unilateral unipedicled DIEPs had a significantly higher rate of revisional elective surgery than unilateral bipedicled DIEPs (40.4% vs 12.9%, p=0.029). Conclusion Our study shows no significant difference in donor site morbidity between unipedicled and bipedicled DIEP flaps. Bipedicled DIEPS have slightly higher donor site morbidity rates, which can be partly explained by longer operative times. There is no significant difference in breast complications and bipedicled DIEP flaps can reduce rates of further elective surgery.

The Use of the Bipedicled Deep Inferior Epigastric Perforator Flap for Unilateral Breast Reconstruction: A Systematic Review and Meta-analysis.

The use of abdominal flaps is recognized as a very advantageous approach for breast reconstruction with gradual refinements leading from the pedicled transverse rectus abdominis musculocutaneous flap to the criterion standard deep inferior epigastric perforator (DIEP) flap and its several variations. A systematic review with meta-analysis attempts to investigate the safety of the bipedicled DIEP flap for unilateral breast reconstruction. The literature search used "PubMed" database, and a relevant study conducted at the Queen Victoria Hospital was also included. The extraction of data included study type, follow-up, patients' age, body mass index, preexisting abdominal scars, timing of reconstruction, operating time, flap inset, pedicles' configuration, flap failure, revision, and complication rates. Proportions were pooled with Freeman-Tukey arcsine transformation, and meta-regression was performed to evaluate whether complication rates were modified by different variables. Fourteen eligible articles provided an overall sample of 486 flaps, with a median follow-up of 18.5 months. In most cases, immediate reconstruction with undivided flap was performed, with equal use of extraflap and intraflap pedicles' configuration. Only 4 cases of flap failure (0.82%) were documented, with 18% overall complications and 3% fat necrosis rate. The forest plot showed significant between-study heterogeneity, and meta-regression revealed marginal positive association between older patient and complication rate. Bipedicled DIEP flap for unilateral breast reconstruction is a technique that maintains the complications rate relatively low in challenging postmastectomy cases. Further comparative studies are needed to substantiate the findings of this study.

The use of bi-pedicled DIEP flap for unilateral breast reconstruction: a 5-year retrospective study

The deep inferior epigastric perforator (DIEP) flap is currently the flap of choice for autologous breast reconstruction. When the amount of tissue transferred needs to be maximised, a bi-pedicled DIEP flap allows harvesting the entire lower abdomen. A retrospective analysis was conducted including patients who had unilateral breast reconstruction with bi-pedicled DIEP flaps between January 2013 and December 2017. Demographic information, operation notes and post-operative course were reviewed. Mann-Whitney-Wilcoxon and Fischer’s exact tests were used to look for a statistically significant association between complications and intra-operative modalities. Forty-four cases were reviewed. Half of these patients underwent delayed breast reconstructions, 40.9% underwent immediate reconstructions and 10% were salvage cases. The majority of the cases (52.3%) had an initial anastomosis of the secondary pedicle to either a side branch (38.6%) or the superior continuity (13.6%) of the primary pedicle (intra-flap anastomosis). Twenty-seven percent of the intra-flap arterial anastomoses were performed using vessel couplers. The remaining 47.7% of the cohort had anastomoses of both pedicles to the internal mammary (IM) vessels anterogradely and retrogradely. There were no flap failures. The cases in which both pedicles were anastomosed with IM vessels had an overall higher complications rate, but were not related to flap failures or anastomotic issues. Intra-flap anastomosis on the other hand is a reliable alternative including the possibility of vessel coupler application to smaller arteries of this approach. In our experience, bi-pedicled DIEP flaps are a safe alternative for unilateral breast reconstruction when the amount of harvested tissue needs to be maximised. Level of evidence: Level III, therapeutic study.

Simultaneous bi-pedicled DIEP and TUG flaps to enhance cosmetic outcome in unilateral delayed breast reconstruction: two flaps with three pedicles for one breast

Autologous breast reconstruction using free tissue transfer allows ‘like-for-like’ restoration of skin and volume following a mastectomy. Even though the majority of patients will require only one flap to restore their anatomy, occasionally, more than one flap is needed to get the best possible cosmetic outcome. For reconstructing the breast of a slim 49-year-old female patient, a bi-pedicled deep inferior epigastric perforator flap was used to replace the missing skin envelope, in combination with a buried transverse upper gracilis flap for volume restoration. The internal mammary vessels between the second and fourth costal cartilages were used as sole vessel recipient site, by preserving their intercostal perforators. Postoperative recovery was uneventful, and the patient was discharged 2 days after her operation. This case shows how a bi-pedicled DIEP with a TUG flap can be used for the challenging scenario in which reconstructive and cosmetic goals are equally important.Level of evidence: Level V, therapeutic study.

Unilateral Autologous Breast Reconstruction with Bi-pedicled, Conjoined Deep Inferior Epigastric Perforator Flaps.

The abdomen remains the most popular and reliable donor site for autologous breast reconstruction. Some patients, however, lack sufficient tissue to recreate an aesthetic breast mound using a single-pedicle, deep inferior epigastric perforator (DIEP) flap, particularly when matching a contralateral native breast. The amount of abdominal skin and/or soft tissue reliably supplied by one vascular pedicle is frequently insufficient to adequately restore the breast skin envelope and "footprint." This study summarizes our experience with using bipedicled DIEP flaps to improve the aesthetic results of unilateral breast reconstruction in such patients. Consecutive patients undergoing unilateral breast reconstruction with bi-pedicled, conjoined DIEP flaps over a 4-year period were retrospectively reviewed. Primary and secondary flap microvascular anastomoses were performed to the antegrade internal mammary (IM) vessels and to either the retrograde IM vessels or a primary DIEP pedicle side branch, respectively. Clinical characteristics and outcomes were recorded. Sixty-three patients underwent immediate (n = 29) or delayed (n = 34) reconstruction, with age and body mass index of 54.1 ± 8.4 years and 26.6 ± 4.7, respectively. Mean follow-up was 14.1 months. Twenty-eight (44.4%) patients received prereconstruction radiation therapy. All patients had preoperative abdominal imaging, including 57 (90.5%) using magnetic resonance angiography. There were no flap losses with three operative interventions for flap salvage. Unilateral breast reconstruction with bipedicled, conjoined DIEP flaps is safe and reliable. These procedures can be performed with a complication profile similar to single-pedicle DIEP flaps. The additional skin and soft tissue available with bi-pedicled flaps allows for greater flexibility in matching the shape and projection of a woman's contralateral breast, and in some cases is necessary to achieve an aesthetically acceptable reconstruction. With growing expectations among breast reconstruction patients, conjoined bi-pedicled flaps represent a tool for meeting their reconstructive needs and exceeding the status quo for aesthetic outcomes.

The Reconstruction Choice for Giant Phyllodes Tumor of Breast: Bi-pedicled Deep Inferior Epigastric Perforator Flap

Phyllodes tumors of the breast are the rarest of all breast neoplasms. Giant phyllodes tumors (>10cm) of the breast have been less discussed in the literature. Reconstruction of the large defect created after wide excision (safety margin >1cm) is a challenge in these patients. We present one technique using a bi-pedicled deep inferior epigastric perforator flap for post-mastectomy breast reconstruction for giant phyllodes tumors. We treated three patients with giant phyllodes tumors between 2013 and 2016. The histological characteristics were benign and borderline; tumor sizes were 18×13×12, 20×16×9.5, and 18×15×9cm. Immediate post-mastectomy reconstruction was performed using bi-pedicled deep inferior epigastric perforator flaps. Flap sizes measured 30×11, 28×12, and 28×13cm. Total operative time, including that for mastectomy, was 285, 425, and 410min. The duration of hospital stay was 12, 13, and 9days. No local recurrence or distant metastasis occurred in the first two patients over a follow-up period of 3years and in the third patient over a follow-up period of 6months. A higher local recurrence rate was associated with positive margins, histological grade, tumor size, and necrosis. Immediate post-mastectomy breast reconstruction may become the preferred option for treatment of giant phyllodes tumors. A bi-pedicled deep inferior epigastric perforator flap conferred adequate leverage for wide excision and resolved scar contracture of the axilla. Good functional and cosmetic results were achieved. 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 .

Use of both antegrade and retrograde internal mammary vessels in the bipedicled deep inferior epigastric perforator flap for unilateral breast reconstruction

Autologous abdominal tissue transfer is a well-established method of breast reconstruction. The deep inferior epigastric perforator (DIEP) flap has the additional benefit of minimal donor site morbidity as it spares the muscle and fascia. Conventional DIEP flaps may not provide adequate volume in cases where the patient is thin, has midline abdominal scars, and/or has a large volume of tissue to replace. One solution is to use a bipedicled DIEP flap, incorporating all the available abdominal tissue. Bipedicled DIEP flaps have been described in a number of different configurations. The literature appears to favor intra-flap anastomosis, with a minimal exposition of two recipient vessels. It has been demonstrated that both the antegrade internal mammary artery (aIMA) and retrograde internal mammary artery (rIMA) are adequate recipient vessels. Here, the authors present a single-center experience with bipedicled DIEP flaps to both the aIMA and rIMA, showing their feasibility and safety. A retrospective review of patients who underwent unilateral breast reconstruction using bipedicled DIEP flaps was performed to assess outcomes. A total of 20 patients who underwent unilateral breast reconstruction using a bipedicled DIEP flap were selected for this study. All of them were previously diagnosed with cancer. There were zero flap failure and zero instance of abdominal hernia or issue with abdominal wall functionality following the surgeries. The series of surgeries described in this study resulted in successful breast reconstruction in 20 women using a bipedicled DIEP flap. The results show that this approach allows for reconstruction in places where a conventional DIEP does not provide adequate volume, achieved safely, and does not increase morbidity. The bipedicled DIEP flap is a viable option for large-volume autologous breast reconstruction, providing ample tissue for successful reconstruction while also allowing for shorter recovery and limited donor site morbidity.

Stacked and bipedicled abdominal free flaps for breast reconstruction: considerations for shaping.

Stacked and bipedicled abdominal flaps are useful in women who require a large breast reconstruction but have relative paucity of abdominal tissue. A new classification system is described to assist the surgeon in achieving the best possible aesthetic outcome. A retrospective review of 25 consecutive stacked and/or bipedicled deep inferior epigastric perforator (DIEP) flap reconstructions was assessed from 2009 to 2014. Demographic data and key variables were prospectively collected in our breast reconstruction database and an aesthetic classification devised. There are four main subtypes, (I) folded; (II) divided; (III) coned; and (IV) divided and folded. Each of these subtypes can be moulded in a symmetrically or asymmetrically fashion depending on the contralateral breast shape together with distribution and consistency of fat within the abdominal flap. Of the 25 patients, three-quarter were immediate reconstruction, with an average age of 48 years and a median follow-up of 2 years 10 months. Just over half the patients (57%) had bipedicle flaps with two recipient donor vessels with the remaining 43% had stacked flaps. The most common recipient sites are the thoracodorsal vessels (62%) and intercostal perforators (26%). The average abdominal pannus weight was 610 grams (SD: 320 grams), with a hemi-abdominal weight of 305 grams. Two patients had haematomas, of which one lost their reconstruction. Another patient had a venous congestion flap which was salvaged. Bipedicled or stacked abdominal flaps allow the all four zones of the abdominal tissue to be used in unilateral breast reconstruction. The approach of tailoring the abdominal flaps to match the contralateral breast reconstruction is largely an art form. The paper aims to bring some meaningful system to aid the surgeon to achieve the best possible outcome with the components presented to them.

Post-operative assessment of perfusion of Deep Inferior Epigastric Perforator (DIEP) free flaps via Pulsatility Index (PI) using a portable colour Doppler sonogram device

PI as an independent indicator of resistance to flow is a widely-accepted alternative index to measurement of flow volume in vessels. This study aimed to determine the normal values and chronological trend of PI of abdominal wall free flaps in breast reconstruction and to revalidate its clinical relevance in post-operative monitoring of these flaps. 47 patients with breast reconstruction using DIEP, MS-TRAM and bi-pedicled DIEP flaps were assessed for PI of the supplying perforator vessels using a hand-held colour Doppler ultrasound device over 6 post-operative days. Triplicate measurements were obtained by one operator once daily concurrently with haemodynamic parameters. DIEP flaps demonstrate a descending trend of PI and resistance to blood flow post-operatively (p=0.005) similar to non-perforator free flaps. MS-TRAM flaps show higher initial PI values and vascular resistance compared to DIEP flaps (p=0.038). PI values show no correlation with haemodynamic parameters (r=0.2, n=38). Flaps with venous insufficiency demonstrate significantly higher values of PI (p=0.03). PI is an objective, non-invasive, efficient, easy-to-measure, reproducible and quickly-responsive indicator of perfusion of DIEP flaps.

Reconstruction of Cicatricial Microstomia and Lower Facial Deformity by Windowed, Bipedicled Deep Inferior Epigastric Perforator Flap

We performed simultaneous facial scar repair and oral aperture open with a windowed, bilateral, bipedicled deep inferior epigastric perforator flap (DIEP flap) in a 20-year-old male patient who had suffered from severe postburn scar of the face and neck in association with serious cicatricial microstomia. DIEP flap is a typical perforator flap that has less donor site morbidity because of a minimal sacrifice of muscles. Since bipedicled DIEP flap can provide the largest skin territory in the lower abdominal wall and ensure a sufficient blood supply to zone IV, it is very suitable for the repair of massive defects of the face and neck. From our challenging case, we learned that bilateral, bipedicled DIEP flap is an excellent option for the repair of large faciocervical defects. Bilateral, bipedicled DIEP flap, which can produce an excellent esthetic and functional outcome, has reliable blood perfusion, provides soft and pliable tissue, and causes the minimal donor-site morbidity.

Evaluation of Facial Allograft Transplantation in Humans in a Cadaver

Evaluation of Facial Allograft Transplantation in Humans in a Cadaver

A Cadaver Study in Preparation for Facial Allograft Transplantation in Humans: Part I. What Are Alternative Sources for Total Facial Defect Coverage?

Reconstruction of facial defects in burn, trauma, and head-neck cancer patients is challenging. The lack of autogenous tissue availability and the need to match facial texture and color are major concerns. Anatomical dissections were performed to search for alternative sources for facial-scalp reconstructions in five cadavers. The composite facial-scalp flaps, radial forearm, anterolateral thigh, bipedicled deep inferior epigastric perforator, and bipedicled scapular-parascapular flaps were harvested. The total surface areas of the facial defects and alternative traditional flaps were measured. The mean surface area for combined facial-scalp flaps and facial flaps without scalp was 1192 +/- 38.2 cm and 675 +/- 22.3 cm, respectively. When compared with the total surface area of the facial-scalp flap, it was found that the radial forearm flap covered 13 +/- 2.58 percent, the anterolateral thigh flap 19 +/- 3.72 percent, the bipedicled deep inferior epigastric perforator flap 35 +/- 1.56 percent, and the bipedicled scapular-parascapular flap 48 +/- 4.64 percent of the defect, respectively. When measurements were taken for coverage of the facial defect without scalp, it was found that the radial forearm flap covered 24 +/- 4.0 percent, the anterolateral thigh flap 34 +/- 6.50 percent, the bipedicled deep inferior epigastric perforator flap 62 +/- 3.03 percent, and the bipedicled scapular-parascapular flap 84 +/- 8.30 percent of the defect, respectively. The authors' cadaver dissection confirmed that none of the conventional cutaneous autogenous flaps are able to cover total facial defects. Currently, the best option for reconstruction of the full facial defect is the autogenous bipedicled scapular-parascapular flap because of its large size and texture. However, perfect match of facial skin texture, pliability, and color can only be achieved by transplantation of the facial skin allograft from the human donor.

Refinements in free flap breast reconstruction: the free bilateral deep inferior epigastric perforator flap anastomosed to the internal mammary artery

Besides the enormous advantages of reconstructing the amputated breast by means of a conventional TRAM flap, the main disadvantage remains the elevation of small (free TRAM) or larger (pedicled TRAM) parts of the rectus abdominis muscle. In order to overcome this disadvantage, the free Deep Inferior Epigastric Perforator (DIEP) skin flap has recently been used for breast mound reconstruction with excellent clinical results. After achieving favorable results with eight unilateral DIEP-flaps, we were challenged by an abdomen with a midline laparotomy scar. By dissecting a bilateral DIEP flap and making adjacent anastomoses to the internal mammary artery we were able to achieve sufficient flap mobility for easy free flap positioning and breast shaping. Intraoperative segmental nerve stimulation, postoperative functional abdominal wall tests and CT-scan examination showed normal abdominal muscle activity. On the basis of a case report, the technical considerations and advantages of anastomosing the bipedicled DIEP flap to the internal mammary artery are discussed.