Bilateral Deep Inferior Epigastric Perforator Flap Research Articles

Learning Curve Analysis for Robotic-assisted Harvest of Deep Inferior Epigastric Perforator Flap

Summary: The deep inferior epigastric perforator (DIEP) flap is the preferred method for autologous breast reconstruction after mastectomy, but risks the development of hernia, bulge, and decreased core strength. Robotic harvest of DIEP vessels may limit abdominal wall morbidity through smaller fascial incisions and preservation of motor nerves. This study shows the expected learning curve (LC) for robotic harvest and compares the LC between a general surgeon (GS) and a plastic surgeon (PS). A retrospective cohort study was performed for patients who underwent bilateral robotic DIEP flap harvest from October 2021 to September 2022. We evaluated robotic pedicle dissection time (DT) and compared the times between GS and PS. We calculated LC for each surgeon using the cumulative sum (CUSUM) method, . The LC was identified as the peak of the CUSUM graph. Forty-four flap dissections were recorded during the collection period: 27 by the PS and 17 by the GS. There was no significant difference in DT between the GS and the PS (P = 0.366), and both surgeons saw a decrease in DT over time. Using the CUSUM method, we see the peak of the plot at patient 9 for the PS and the peak of the plot at patient 5 for the GS, after which cumulative DT decreased. As robotic harvest of DIEP flaps becomes accepted, plastic surgeons who wish to incorporate it into their practice may achieve proficiency in their DT within 10 flap harvests and a similar DT compared with robotic-trained GSs.

Optimizing Intraflap Anastomosis of Conjoined Bilateral DIEP Flap for Breast Reconstruction: Planning, Execution and Outcomes in 201 patients.

Conjoined bilateral deep inferior epigastric perforator (DIEP) flap with intraflap anastomosis is an efficient approach for breast reconstruction, enabling the use of almost the entire abdominal tissue. Variations in bilateral DIEA anatomy may make it challenging to apply this technique consistently. This study aimed to derive optimal strategies for achieving reliable conjoined bilateral DIEP flap with intraflap anastomosis universally. For all consecutive patients undergoing conjoined bilateral DIEP flap-based breast reconstruction from 2009 to 2023, preoperative planning and intraoperative execution for the pedicle configurations were reviewed. Their postoperative outcomes were evaluated. In total 201 patients were included, with no cases requiring conversion to extraflap anastomosis. In preoperative planning, candidates for recipient vessels for intraflap anastomosis were typically selected based on DIEA branching patterns, identified through computed tomographic angiography; Type I (single trunk) prioritizing the superior continuation, type II (two main trunks) considering a side branch, and type III (three main trunks) favoring the first bifurcating branch. Comparing candidates from bilateral DIEA, the primary pedicle was determined, providing larger recipient vessels. Most cases followed the planned approach smoothly, however 28 required intraoperative changes, mostly aimed at securing larger recipients by changing the primary pedicle or harvesting more caudally located perforators to obtain larger superior continuations. Four perfusion-related complications developed, which were resolved successfully without flap failure. Our results suggest an efficient strategy for securing a reliable recipient vessel, tailored to patient anatomy, in conjoined bilateral DIEP flap breast reconstruction with intraflap anastomosis, leading to achieving optimal outcomes.

DIEP Flap versus PAP Flap versus LAP Flap: A Propensity-Matched Analysis of Aesthetic Outcomes, Complications, and Satisfaction.

As free breast reconstruction options evolve, a patient- and body-centric approach can distinguish refined aesthetic outcomes. Although deep inferior epigastric perforator (DIEP), profunda artery perforator (PAP), and lumbar artery perforator (LAP) flaps are all safe and effective options for breast reconstruction, a head-to-head analysis of these 3 flaps has not been performed. The authors aim to compare these 3 flaps based on outcomes, BREAST-Q scores, and aesthetic results. After institutional review board approval, a retrospective review in a Research Electronic Data Capture database-guided analysis was conducted of patients who underwent simultaneous bilateral DIEP, PAP, or LAP flaps at a single academic institution. Propensity matching was performed to match 50 patients (100 flaps) in each group. Postoperative complications and BREAST-Q satisfaction survey scores were documented, and crowdsourcing was carried out to determine aesthetic preference in the general population. Overall patient postoperative breast satisfaction was insignificantly different across the 3 flap groups ( P > 0.05). Associations were seen with LAP flap donor-site seromas, PAP flap donor-site infections and wounds, and DIEP flap breast wounds and flap necrosis ( P < 0.05). DIEP flaps had a higher raw score average on crowdsourcing survey, although LAP flaps were rated significantly higher aesthetically than DIEP and PAP flaps when undergoing a matched head-to-head analysis ( P < 0.05). DIEP, PAP, and LAP flaps all have favorable outcomes with insignificantly different long-term satisfaction, with comparable complication profiles. Although DIEP flaps may initially score higher, LAP flaps score higher frequently when analyzed in a head-to-head analysis. For these reasons, tailoring breast reconstruction to the patient's anatomy and morphology provides optimal outcomes. Therapeutic, III.

Simultaneous Co-surgeon Deep Inferior Epigastric Perforator (DIEP) Flap Breast Reconstructions: Feasibility and Clinical Outcomes.

A co-surgeon model is known to be favorable in microvascular breast reconstruction, but simultaneous co-surgeon deep inferior epigastric perforator (DIEP) flap cases have not been well-studied. The authors hypothesize that performing two simultaneous co-surgeon bilateral DIEP flap reconstructions results in non-inferior clinical outcomes and may improve patient access to care. A single-institution, retrospective cohort study was performed utilizing record review to identify all cases of co-surgeon free-flap breast reconstructions over a 38-month period. Patients who underwent simultaneous bilateral DIEP flap breast reconstructions with the same two co-surgeons were identified. The control group consisted of subjects who underwent non-simultaneous reconstruction by the same co-surgeons within the same, preceding, or following month of those in the study group. Primary outcome variables were 90-day postoperative complications, while secondary outcomes were operating time, ischemia time, and length of stay. Descriptive statistics, univariate and multivariable regression analyses were performed. Overall, 137 subjects were identified and 64 met the inclusion criteria (n=28 study, n=36 control). There were no statistically significant differences between groups in body mass index, radiation, trainee experience, flap perforator number, immediate/delayed reconstruction, or length of stay. There were also no statistically significant differences in complications, including flap loss, anastomosis revision, take-back to the operating room, or re-admission. Operative time was longer in the simultaneous DIEP group (540.5 vs. 443.5 min, p<0.01), but ischemia time was shorter in the simultaneous group (64.0 vs. 80.5min, p<0.01). A simultaneous co-surgeon approach to bilateral DIEP flap reconstruction may improve access to care and does not result in a higher complication rate compared with non-simultaneous bilateral DIEP flaps.

Initial Experience with Unidirectional Barbed Suture for Abdominal Donor Site Closure in Deep Inferior Epigastric Perforator Flap Breast Reconstruction.

The deep inferior epigastric perforator (DIEP) flap is a predominant technique for autologous breast reconstruction. However, the best method of abdominal fascial closure in this technique is not well defined. This study details our initial experience with unidirectional barbed suture-only repair of abdominal donor site fascia. Patients who underwent DIEP flap breast reconstruction and abdominal fascial closure with Stratafix Symmetric Polydioxanone PDS Plus were retrospectively reviewed. Information regarding pertinent patient history, medical comorbidities, risk factors, and surgical technique was extracted, along with the incidence of eight separate postoperative abdominal surgical site occurrences. Retrospective review identified 43 patients who underwent 19 unilateral and 24 bilateral DIEP flap breast reconstruction procedures (n = 67). Average patient follow-up was 791 days (range 153-1769). Six patients (14%) had a complication of the donor site. Seroma was most frequent (n = 3, 7%), followed by surgical site infection (n = 2, 5%). One patient had incisional dehiscence (2%) and another patient developed bulging (2%). No patients had chronic pain, weakness, hematoma, or hernia postoperatively. Patients with donor site complications had a history of abdominal/pelvic surgery significantly more often than the patients without donor site complications (100% versus 49%; P = 0.032). Abdominal fascial repair with Stratafix Symmetric suture alone led to low rates of abdominal donor site morbidity, including no hernia and rare bulging, following DIEP flap breast reconstruction. Additional advantages of this technique may be reduced operative times and lower operative costs compared with alternative methods of fascial repair, although prospective and randomized studies are warranted.

Operative Time Predicts Long-Term Abdominal Morbidity and Complication Requiring Treatment after DIEP Flap Breast Reconstruction.

The relationship between skin-to-skin operative time and long-term complications, as well as complications requiring treatment, after deep inferior epigastric perforator (DIEP) flap breast reconstructions has not been thoroughly investigated. The study objective was to evaluate if operative time would independently prognosticate the type and number of treated complications, as well as long-term abdominal morbidity. Patients who underwent bilateral DIEP flaps from 2010 to 2021 by two senior surgeons with standardized surgical and postoperative protocols were retrospectively reviewed. Inclusion required at least 1 year of postoperative follow-up. Extensive multivariable regression analyses were utilized to adjust for potential confounders, including measures of intraoperative complexity. Three hundred thirty-five patients were entered into multivariable analyses. After risk adjustment, there was a significant increase in the risk of all treated complications per hour. Each hour of operation increased risk of complications requiring extended hospital stay for treatment by 25%, flap-site complications requiring readmission treatment by 24%, and flap-site complications requiring extended hospital stay for treatment by 26% (all p < 0.0001). Long-term abdominal morbidity (abdominal bulge) increased by 25% per hour of operative time (p < 0.0001). The number of complications requiring treatment, abdominal donor-site complications, and complications requiring extended hospital stay for treatment had statistically significant linear relationships with the duration of surgery (all p < 0.05). Operative time predicts long-term abdominal morbidity and complications requiring treatment, especially impacting the odds of developing abdominal bulges and complications requiring extended hospital stay for treatment or readmission treatment. This study emphasizes the importance of reducing operative time to improve DIEP flap breast reconstruction outcomes.

Novel Port Placement in Robot-Assisted DIEP Flap Harvest Improves Visibility and Bilateral DIEP Access: Early Controlled Cohort Study.

To minimize donor-site damage, robot-assisted (RA) deep inferior epigastric perforator (DIEP) flap harvest has been suggested. Current robotic approaches favor port placement, which either does not allow a bilateral DIEP flap harvest through the same ports or necessitates additional scars. In this article, the authors propose a modification of port configuration. In a retrospective controlled cohort study, RA-DIEP and conventional DIEP surgery were compared. The perforator and pedicle were visualized conventionally until the level behind the rectus abdominis muscle. Next, the robotic system was installed to dissect the retromuscular pedicle. The authors assessed patient age; body mass index; history of smoking, diabetes mellitus, and hypertension; and additional surgical time. The length of the anterior rectus sheath (ARS) incision was measured. Pain was quantified using the visual analogue scale. Donor-site complications were assessed. Thirteen RA-DIEP flaps (11 unilateral and two bilateral) and 87 conventional DIEP flaps were harvested without flap loss. The bilateral DIEP flaps were raised without readjustments of the ports. The mean time for pedicle dissection was 53.2 ± 13.4 minutes. The length of the ARS incision was significantly shorter in the RA-DIEP group (2.67 ± 1.13 cm versus 8.14 ± 1.69 cm; 304.87% difference; P < 0.0001). There was no statistical difference in postoperative pain (day 1: 1.9 ± 0.9 versus 2.9 ± 1.6, P = 0.094; day 2: 1.8 ± 1.2 versus 2.3 ± 1.5, P = 0.319; day 3: 1.6 ± 0.9 versus 2.0 ± 1.3, P = 0.444). Preliminary results show that the authors' RA-DIEP approach is safe and allows dissection of bilateral RA-DIEP flaps with short ARS incision lengths. Therapeutic, III.

Deliberate Practice in DIEP Flap Breast Reconstruction: An Immediate and Sustained Decrease in Morbidity and Operative Time.

Deep inferior epigastric perforator (DIEP) flaps are nuanced, multistep, complex procedures. Recent studies have hinted that operational flow can be a sensitive barometer for safety, efficiency, and overall outcomes. The authors critically assess the utility of implementing deliberate practice and process mapping as a research tool in the context of morbidity and operative time. Co-surgeons at a university hospital implemented deliberate practice and performed two prospective process analysis studies evaluating critical steps in DIEP flap reconstruction. During the 9-month period (June of 2018 to February of 2019), the flap harvest and microsurgery steps were assessed. During the 8-month period (January to August of 2020), the analysis was expanded to encompass the entire operation. To evaluate the immediate and sustained impact of process analysis, 375 bilateral DIEP flap patients were divided into eight consecutive 9-month intervals completed before, during, and after the two studies. Using risk-adjusted multivariate regressions, morbidity and operative time were compared between groups. Time intervals completed before the first study had comparable morbidity and operative time. During the first study, there was an immediate 83.8% ( P < 0.001) decreased risk in morbidity. Operative time during the second study decreased by 2.19 hours ( P < 0.001). Morbidity and operative time continued to decrease until the end of data collection [62.1% decreased risk in morbidity ( P = 0.023) and decreased operative time of 2.22 hours ( P < 0.001)]. Deliberate practice and process analysis are powerful tools. Implementation of these tools can generate immediate and sustained decreases in morbidity and operative time for patients undergoing procedures such as DIEP flap breast reconstruction. Therapeutic, III.

DIEP flap in breast reconstruction: A morbidity study of bilateral versus unilateral reconstruction

The Deep Inferior Epigastric Perforator (DIEP) flap is a modality in breast reconstruction of choice. Despite its well-documented benefits and complications, a lack of evidence remains with regards to the risks of performing a bilateral versus a unilateral reconstruction. As such, we sought to compare the rates of adverse outcomes in the perioperative and postoperative periods associated with a unilateral versus a bilateral DIEP flap breast reconstruction. A retrospective cohort study of 178 consecutive patients undergoing unilateral versus. bilateral deep inferior epigastric perforator flap breast reconstruction was performed at our tertiary care center over a 3-year period. Data on demographics, operative time, intraoperative and postoperative complications, and surgical re-exploration, were extracted for both groups. Statistical analysis was performed on a per-flap basis. A total of 157 unilateral and 42 bilateral deep inferior epigastric perforator flaps were identified. The rate of intra-operative complications was 12.1% for unilateral versus. 4.8% for bilateral flaps (P=0.26). Total post-operative complications rates were 30.6% for unilateral versus 54.7% for bilateral flaps (P=0.003). Surgical re-exploration was performed in 12.7% of unilateral and 11.9% of bilateral cases (P=0.88). The rate of total flap loss was similar between types of reconstruction, occurring in 2.5% of unilateral vs. 2.4% of bilateral flaps (P=1). This study demonstrates the rate of complications per flap is significantly higher in bilateral versus unilateral deep inferior epigastric perforator flap breast reconstruction. Bilateral DIEP breast reconstruction should be decided on a case-by-case basis. Prognostic/Risk Study, Level II.

Should Sickle Cell Trait Be a Contraindication to Breast Reconstruction?—A Case Series Analysis

Abstract Background While sickle cell disease has long been considered a contraindication to breast free flap reconstruction, there have been less definitive decisions about the impact of sickle cell trait on these procedures. We sought to analyze the patients with sickle cell trait who underwent free deep inferior epigastric perforator (DIEP) flap and pedicled latissimus dorsi (LD) flap at a single institution to determine the reconstructive outcomes. Methods Patients with sickle cell trait who underwent breast free DIEP and pedicled LD reconstruction from 2007 to 2021 at a single institution by the lead surgeon were analyzed for demographics and surgical outcomes. Results Four patients were identified as having sickle cell trait and having undergone a breast flap reconstruction. The average age of the patients was 54 years, median body mass index was 25, and past medical history was notable for one patient being a current smoker, and one patient having hypertension. Two patients received a unilateral free DIEP flap, one received a bilateral free DIEP flap, and one received a unilateral pedicled LD flap for a total of five flaps in four patients. Three of the patients received prior hormone therapy, one received prior radiation therapy, and one received prior chemotherapy. There were no instances of flap failure, vessel thrombosis, pulmonary embolism, or deep venous thrombosis. One patient experienced wound dehiscence. Conclusion In this case series we present four patients with sickle cell trait who successfully underwent breast flap reconstruction without any instances of flap or systemic thrombosis. More work is needed to determine how to pre- and postoperatively optimize patients with sickle cell trait for favorable breast flap reconstruction outcomes.

Simultaneous Contralateral Autologous Breast Augmentation during Unilateral Breast Reconstruction Utilizing Deep Inferior Epigastric Flaps.

Background:It is predicted that 281,550 new cases of invasive breast cancer and 49,290 new cases of ductal carcinoma in situ will be diagnosed this year. In this study, we will detail our experience with simultaneous contralateral autologous breast augmentation during unilateral breast reconstruction utilizing bilateral deep inferior epigastric perforator (DIEP) flaps.Methods:A retrospective analysis of patients who underwent simultaneous contralateral autologous breast augmentation during unilateral breast reconstruction utilizing bilateral DIEP flaps by the senior surgeons at Beaumont Health Systems, Royal Oak, was conducted. Demographic data, operative details, complications, medical comorbidities, and patient outcomes were retrospectively analyzed.Results:Seven patients who met the inclusion criteria were identified. One patient underwent immediate reconstruction with DIEP flaps, one patient had a history of lumpectomy and underwent delayed partial breast reconstruction, three patients had delayed unilateral DIEP breast reconstruction with contralateral breast augmentation, and two patients had previous augmentations that were revised. All patients examined in this review tolerated the procedures well and had clinically viable flaps along with superior aesthetic outcomes.Conclusions:This technique can be applied to various clinical conditions, including immediate breast reconstruction, delayed breast reconstruction, and salvage for failed implant-based reconstruction, leading to optimal patient outcomes and satisfaction. Unilateral breast reconstruction with simultaneous contralateral autologous breast augmentation utilizing bilateral DIEP flaps is a surgical technique that more plastic surgeons should utilize.

120. Operative Time is an Independent Predictor of Postoperative Outcomes in Bilateral DIEP Flap Breast Reconstruction: A Multivariate Analysis of 1000 Flaps

Purpose: The deep inferior epigastric perforator (DIEP) flap is the gold standard autologous breast reconstruction, with a rapid increase in regularity in recent years. Operative time (OT) as a risk factor for adverse postoperative outcomes in microvascular breast reconstruction has not been thoroughly investigated. This study evaluates the impact of OT on length of stay (LOS), overall morbidity, individual complications, and unplanned reoperation (UR) in DIEP flaps, with a primary objective of identifying a clinically relevant time of decreased risk. Methods: Patients treated with bilateral DIEP flaps from 2010-2021 by two senior surgeons (NTH, SST) with standardized surgical and postoperative protocols were retrospectively reviewed. 1000 flaps (500 patients) were analyzed with multivariate regressions to adjust for potential confounders, including microsurgeon experience, and isolate the impact of OT on postoperative outcomes. We rounded the 25%ile, 50%ile, and 75%ile of OT quartiles (I.e. 4.92, 6.60, and 8.87 hours) to the nearest hour (I.e. 5, 7, and 9 hours) for ease of use as an easy-to-follow guideline for OT intervals. To identify a cutoff, beyond which risk for postoperative complications, extended LOS (eLOS, defined as ≥5 days), and UR significantly increases, adverse outcomes were compared amongst OT intervals. Results: The occurrence of all adverse outcomes with more than one incidence was associated with longer operative times. Procedures with and without complications had an average of 8.05±3.29 and 6.33±2.51 hours (p<0.001) respectively. With risk-adjustment, each hour of OT increased morbidity by 22% (p<0.001) and LOS by 4.8 hours. Procedures >5 hours had 3.9, 4.8, and 2.6-fold increased risk of UR (p=0.029), eLOS (p=0.007), and overall complications, respectively. Breast fat necrosis, abdominal donor-site morbidity, and medical complications also had significantly higher risk after 5 hours. Lastly, a risk-adjusted linear regression showed that LOS can be calculated from OT: LOS (days) =1.702 + 0.201 x OT (hours) (p<0.001, R2=0.369). Conclusions: For the first time, operative time is shown as an independent predictor of morbidity, LOS, and UR in DIEP flaps, with significantly greater risk >5 hours. The findings emphasize the importance of decreasing OT through efficiency models, such as process analysis, team-based protocols, and co-surgery.

Impact on Patient’s Appearance Perception of Autologous and Implant Based Breast Reconstruction Following Mastectomy Using BREAST-Q

IntroductionThe purpose of this study is to determine if there is a better quality of life with one of the two techniques and if the results are in line with those already present in the literature. The hypothesis from which we started is to demonstrate that cancer patients who undergo a deep inferior epigastric perforator flap (DIEP) breast reconstruction surgery are more satisfied and have a higher level of quality of life compared to those subjected to an intervention of reconstruction with prosthesis.Materials and MethodsAll patients undergoing reconstruction from January 2010 to July 2018 were eligible for inclusion. This is a retrospective cohort study carried out using the patients of two plastic surgery departments who have undergone monolateral or bilateral implant-based or DIEP flap breast reconstruction. We administered BREAST-Q questionnaire electronically almost 2 year after surgery. Patients were divided into two groups: implant-based and autologous breast reconstruction with DIEP flaps. Baseline demographics and patient characteristics were analyzed using a Students t-test (continuous variables) or Chi-square/Fisher’s exact test (categorical variables). Mean standard deviation BREAST-Q scores were reported for the overall cohort and by modality for the postoperative period. The linear regression model was applied to all BREAST-Q score with all predictor factors.ResultsOf the 1125 patients involved, only 325 met the inclusion criteria and were enrolled in this study; specifically, 133 (41%) DIEP and 192 (59%) prosthetic reconstructions. We summarized the results of the principal scales of BREAST-Q module: satisfaction with breast, psychosocial well-being, satisfaction with outcome, and sexual well-being in which the autologous group was always more satisfied. We reported results of all linear regression models with higher values for the DIEP group independently from predictors.ConclusionThis is the first study performed on the Italian population that compares autologous surgical techniques with the implantation of breast implants. In this population, DIEP is considered the technique that leads to the highest satisfaction in all BREAST-Q scores.Level of Evidence IVThis 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.

Midline epigastric scars can be associated with higher umbilical complications following DIEP flap harvest

Umbilical complications can be relatively common after breast reconstruction with deep inferior epigastric perforator (DIEP) flaps. The medial umbilical ligaments and the ligamentum teres hepatis can be the sole blood supply to the umbilicus after a DIEP flap harvest. Prior incisions along the epigastric midline may disrupt the ligamentum teres hepatis. In this retrospective study, we assess the influence of previous midline epigastric scars on umbilical complications after DIEP flap harvest. All patients who underwent breast reconstruction with DIEP flaps were identified at an academic institution over six years. Relevant sociodemographic and clinicopathologic factors were reviewed in the electronic medical records. Univariate and multivariate analyses were performed to determine the role of clinical variables to predict the chance of umbilical complications. A total of 243 patients met inclusion criteria, with 39 patients (16%) having prior surgery utilizing midline epigastric incisions. Twenty-one patients had umbilical complications. No significant difference in patient characteristics was found between patients with and without prior midline epigastric scars. Patients with a history of previous midline epigastric scars had a higher rate of umbilical complications (20.5% vs. 6.4%, p < 0.01). Bilateral medial row perforator-based DIEP flap harvest was also related to a higher rate of umbilical complications (18.4% vs. 6.2% p < 0.01). Previous midline epigastric scars are associated with higher rates of umbilical complications after DIEP flap harvest. Bilateral medial row perforator-based DIEP flap harvest exacerbates the rate of umbilical complications and should be avoided in patients with prior midline epigastric incision whenever possible.

Economic Impact of Refinements in ERAS Pathways in DIEP Flap Breast Reconstruction.

Enhanced recovery after surgery (ERAS) protocols at our institution have led to an expected decrease in hospital length of stay and opioid consumption for patients treated with deep inferior epigastric perforator (DIEP) flaps for breast reconstruction. We look to examine the economic patterns across these years to see the impact of costs for the patient and institution. This study retrospectively evaluated consecutive patients treated with bilateral DIEP flaps for breast reconstruction between October 2015 and August 2020. We categorized the cases into three categories: pre-ERAS, ERAS, ERAS + bupivacaine. Primary outcomes observed included the contribution margin per operating suite case minute and total cost to the patient. An analysis of variance determined whether there was a difference between the three groups and a Tukey post-hoc analysis made pairwise comparisons. A p-value < 0.05 was significant. A total of 268 cases of bilateral DIEPs performed by the two senior authors were analyzed in this study. Seventy-four cases were pre-ERAS, 72 were ERAS, and 122 were ERAS + bupivacaine. There was a statistical difference between the contribution margin per operating minute. A Tukey post hoc test revealed that the average contribution margin per operating suite case minute was significantly higher for the ERAS and ERAS + bupivacaine compared with the pre-ERAS groups.There was a statistically significant difference between the total cost to the patients. A Tukey post hoc test revealed that the average total cost to the patient was statistically significantly lower for the ERAS and ERAS + bupivacaine compared with the pre-ERAS group. Implementation of ERAS and continued improvements in ERAS resulted in significantly decreased costs for the patient and increased profitability for the hospital. Investing in improvements to ERAS protocols can improve profitability for the institution while simultaneously improving costs and access to care for patients in need of breast reconstruction.

Deconstructing the Reconstruction: Evaluation of Process and Efficiency in Deep Inferior Epigastric Perforator Flaps

Sir: We read with great interest the article by Haddock and Teotia entitled, “Deconstructing the Reconstruction: Evaluation of Process and Efficiency in Deep Inferior Epigastric Perforator Flaps.”1 This article shares the authors’ impressive experience with deep inferior epigastric perforator (DIEP) flap breast reconstruction, and we applaud their use of process analysis to enhance operating efficiency with a common yet highly variable procedure. The authors determined eight critical maneuvers focused on flap harvest (n = 5) and microsurgery (n = 3), tracking completion time of bilateral DIEP flap breast reconstruction as the primary outcome. They reported a 73-minute reduction in total operative time in their process-mapping group compared to their control cohort the previous year. Although the authors note that they have included steps considered to be critical and “most technically demanding,” we recommend including two key postanastomotic steps that we believe are equally important: (1) flap inset and (2) flap tailoring. Meticulous flap inset and tailoring are critical to achieving an aesthetic breast reconstruction, the primary goal to which all other steps contribute. Furthermore, this is often when focus dissipates given the significant technical demand of prior steps and near completion of the procedure. Although process mapping focuses on efficiency, it also ensures patient safety and reproducibility of results.2 Once anastomoses are performed and flap inset begins, the perforators and anastomoses are vulnerable to iatrogenic injury, either from mishandling, unintended kinking/twisting, or even misadventures in drain or suture placement.3 Specific decisions and technical steps in flap inset and tailoring can directly correlate with postoperative results and the potential need for secondary revisions.4 Flap inset details include rotation and positioning and ensuring superior pole contouring, particularly medially at the site of rib removal to avoid hollowing.5 The inframammary fold should be maintained or reestablished if inferior migration occurs with tighter closure. Ensuring proper pedicle lie and avoiding kinking can mitigate undue complications.6 Flap tailoring depends on mastectomy type but can include gentle soft-tissue tapering to avoid visible stepoffs. Skin paddle design maintains certain process-oriented principles (e.g., shape, size, and signal monitoring), and circumferential dermal release around the skin paddle is generally beneficial.7 In their discussion, Haddock and Teotia state, “We elected not to include the nonflap time, as the flap inset tends to have much greater variability based on the specifics of the patient and timing of reconstruction.…” We commend the authors for highlighting the patient-specific nature of this surgery. However, there exists significant variability within the eight critical steps outlined. For example, in step 4, “pedicle dissection to groin,” they note “sensory nerves are maintained if sensory coaptation is planned” and if motor nerves are “between two perforators, the nerve is cut and coapted after harvest.” Technical variability and decision-making occurs in each of these steps, not dissimilar to flap inset and tailoring.8 We congratulate the authors on a well-informed study, highlighting critical maneuvers for DIEP flap optimization and efficiency. Attention to postanastomotic steps of flap inset and tailoring should be considered in the next evolution of process mapping and analysis in DIEP flap breast reconstruction. DISCLOSURE The authors have no financial interest to declare in relation to the content of this work. David A. Daar, M.D., M.B.A.Ara A. Salibian, M.D.Jordan D. Frey, M.D.Nolan S. Karp, M.D.Mihye Choi, M.D.Hansjörg Wyss Department of Plastic SurgeryNew York University Langone HealthNew York, N.Y.

When to assess the DIEP flap perfusion by intraoperative indocyanine green angiography in breast reconstruction?

BackgroundAlthough the indocyanine green angiography (ICGA) has been used for years in the assessment of Deep Inferior Epigastric Perforator (DIEP) perfusion, it has not yet been established when it should be performed during the surgery. The aim of this study is to evaluate whether it is better to perform the test on the donor or recipient sites. MethodsIntraoperative perfusion of 46 DIEP flaps was assessed twice, on the donor and recipient sites. Differences between both ischemic areas of each flap were statistically analyzed. In addition, perforator location and risk factors were evaluated in order to assess whether they are associated with changes in the perfusion of the flap between both sites. ResultsDifferences between ischemic areas on the donor and recipient sites were statistically significant (p = 0.012). However, in most cases (82.6%) the ischemic area was the same on both sites, and the final flap design only changed in two cases (4.3%) because of the ICGA findings on the recipient site. Besides, performing the ICGA on the donor site facilitated the identification of the best perfused areas, allowed a better planning of its placement into the recipient site, and also can be useful to choose the best perforator. Bilateral DIEP flap, lateral location of the perforator and tobacco use had a statistically significant association with lower probability to increase the perfusion area between both sites. Conclusionsseveral advantages have been found in performing the ICGA on the donor site to assess the perfusion of the DIEP flap.

Immediate Bilateral Breast Reconstruction Using Abdominally Based Flaps: An Analysis of the Nationwide Inpatient Sample Database.

Bilateral mastectomy rates are increasing in the United States. The abdomen is the most common harvest site for autologous reconstruction. Nationwide data were examined to determine differences in hospital charges, length of stay (LOS), and early postoperative complications following immediate bilateral pedicled transverse rectus abdominis myocutaneous (pTRAM), free TRAM (fTRAM), deep inferior epigastric perforator (DIEP), and superficial inferior epigastric artery (SIEA) perforator flaps and were compared with unilateral reconstruction. Patients who underwent immediate bilateral breast reconstruction using a single method of abdominally based reconstruction were identified using the 2009 to 2014 Nationwide Inpatient Sample Database. Outcomes included total hospital charges, LOS, and immediate postoperative complications. We identified 13,348 cases of bilateral mastectomy with a single type of immediate bilateral autologous flap reconstruction. The majority were bilateral DIEP flaps. Mean total cost for bilateral pTRAM, fTRAM, DIEP, and SIEA flaps was US $21,886.80, US $28,839.40, US $30,051.30, and US $33,784.90, respectively (p < 0.0001). Mean LOS for bilateral pTRAM, fTRAM, DIEP, and SIEA was 4.3, 4.9, 4.5, and 5.4 days, respectively (p = 0.0002), and hematoma rates were 1.93, 2.61, 3.68, and 16.59%, respectively, (p = 0.0001), whereas return to the operating room for vascular anastomosis revision was 0, 1.63, 1.99, and 19.07%, respectively (p < 0.0001). Cost is less for unilateral pTRAM, fTRAM, and DIEP flaps (p < 0.0001). LOS is shorter for unilateral fTRAM versus bilateral (p < 0.0001). No differences were appreciated between unilateral and bilateral hematoma and reoperation rates for any reconstruction (p > 0.1). Immediate complication rates were higher in bilateral free flaps compared with bilateral pedicled flaps. pTRAM and fTRAM flap reconstructions are still performed frequently with acceptable immediate results without considering long-term morbidity, aesthetics, and abdominal muscle function. Bilateral SIEA free flaps were associated with significantly higher total cost, LOS, and complication rates compared with other groups. Complications were similar between unilateral and bilateral reconstruction procedures. While cost is significantly greater for bilateral procedures compared with unilateral pTRAM, fTRAM, and DIEP flaps, it is not doubled.

Abstract P5-16-12: Implementation and outcomes of a microsurgical breast reconstruction program at a public cancer center in Mexico

Abstract Background: Breast cancer (BC) is the most common malignancy in Mexico, and although many Mexican women need breast reconstruction, this is not covered by most public insurance schemes. The National Cancer Institute of Mexico (INCan), located in southern Mexico City provides care to uninsured individuals with all types of malignancies, including BC. In 2012, INCan received a grant from the Mexican federal government in order to establish the “Post-Mastectomy Program” (PMP), aimed at providing free breast reconstruction to women after mastectomy. Here, we describe the implementation and outcomes of our microsurgical breast reconstruction program. Methods: We retrospectively reviewed medical records of all patients undergoing microsurgical breast reconstruction after mastectomy at INCan between the establishment of the PMP in 01/2013 and until 12/2017. Sociodemographic, clinical and surgical characteristics were collected. We also recorded for the presence of complications directly related to the reconstructive procedures, including local complications (infections, necrosis, thrombosis etc.), flap loss, need for reoperation and hospitalization time. Data were analyzed using descriptive statistics such as means, medians and proportions. Results: 161 microsurgical breast reconstructions were conducted at INCan between 01/2013 and 01/2017, ranging from 23 in 2013 to 41 in 2016. Median patient age was 45 years (y) (21-66), and 57% had &amp;lt; high school education. 2.5% had diabetes, 9.9% hypertension, and 2.5% rheumatologic diseases. Median body mass index was 26.8 (18.2-39), 82.6% were non-smokers and 46.5% (n = 108) had previous abdominal scars. Regarding reasons for mastectomy, 67.7% were due to invasive BC, 11.8% to ductal carcinoma in situ, and 5.6% to BRCA mutations. Of the 109 invasive carcinomas, 21.8% were stage I, 57.3% stage II, and 20% stage III; 21.7% received neoadjuvant chemotherapy. 125 patients underwent immediate reconstruction, of which 89 used unilateral deep inferior epigastric perforator flaps (DIEP), 35 bilateral DIEPs, and 1 other technique. Mean preoperatory albumin was 4.2g/dL (SD 0.35), while mean preoperatory hemoglobin was 14.2g/dL (SD 1.2). 41.6% of the patients (n = 67) had at least one surgical complication, with the most common being delayed wound healing in 17% and fat necrosis in 14%. 26% of patients had to be reoperated, and flap loss occurred in 13% (n = 21). No differences were noted in the clinical or surgical characteristics of patients with or without flap loss. Median length of stay was 6 days (range 2-17). Conclusions:This is the first detailed description of the outcomes of a microsurgical reconstruction program in a country with limited resources. Developing and implementing such a program is feasible, and may provide access to breast reconstruction to women who would normally be unable to obtain it. Citation Format: Vargas-Salas D, Figueroa-Padilla J, Soto-Perez-de-Celis E, Maciel-Miranda A, Santamaria E, Zacarías-Gutiérrez LM, Cabrera-Galeana P, Bargallo-Rocha E. Implementation and outcomes of a microsurgical breast reconstruction program at a public cancer center in Mexico [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P5-16-12.

Application of dual-pedicle abdominal flap for unilateral breast reconstruction

To explore the effectiveness of dual-pedicle abdominal flap for unilateral breast reconstruction. Between March 2014 and March 2018, a clinical data of 19 female patients underwent dual-pedicle abdominal flap reconstruction because of unilateral mastectomy defect was reviewed retrospectively. The median age was 45 years (range, 32-51 years), including 3 immediate breast reconstruction and 16 delayed breast reconstruction, and left side in 7 cases and right side in 12 cases. Unilateral breast reconstruction were performed for 8 patients with unilateral pedicle transverse rectus abdominis musculocutaneous (TRAM) flap and contralateral free TRAM flap, for 3 patients with pedicle TRAM flap and contralateral deep inferior epigastric perforator (DIEP) flap, for 7 patients with bilateral DIEP flaps, for 1 patient with free muscle-sparing TRAM flap and contralateral DIEP flap. The size of abdominal flap ranged from 24 cm×7 cm to 43 cm×13 cm. The donor sites were closed directly. Vascular crisis ocuurred in 1 flap and relieved after surgical exploration. The other flaps survived. Poor wound healing in abdominal incision occurred in 1 patient and was successfully treated with debridement. The other donor sites healed without any other complication. The patients were followed up with a median period of 12 months (range, 4-42 months). Four patients received reparative operation of their reconstructive breast, and 2 patients received mamopexy of the contralateral breast due to mastoptosis. The abdominal BREAST-Q score was 84.1±11.7, chest score was 86.5±8.9, and breast score was 67.6±16.4 at last follow-up. The dual-pedicle abdominal flap for unilateral breast reconstruction provides adequate soft tissue volume and good blood supply. It is a reliable and effective breast reconstructive method for patients who need large tissue volume to make symmetric with the contralateral breast, or slim patients with few tissue in the donor site, or patients with scars in the donor site, especially vertical abdominal scars.