Deep Inferior Epigastric Artery Research Articles

An Effective Protocol for Perioperative Venous Thromboembolism Prophylaxis in DIEP Flap Breast Reconstruction: A Single Institution Retrospective Review.

Deep inferior epigastric artery perforator (DIEP) free flap breast reconstruction is one of the most highly used procedures for autologous breast reconstruction. Many venous thromboembolism (VTE) risk assessment models have been proposed in breast reconstructive surgery, including the widely used Caprini score. However, a paucity of data suggests an effective standardized VTE protocol. The purpose of this study was to determine the rate of VTE in our DIEP flap patients who were treated with this protocol. A retrospective single-center review of DIEP flap breast reconstruction from 2016 to 2021 was performed. Data were collected on 554 patients and 893 flaps including demographics, intraoperative and perioperative details, and postoperative course. Patients who were not treated with our standard protocol were excluded. Data were analyzed with alpha = 0.05. The average age was 50.4 ± 9.9 years, and the total follow-up time was 16.9 ± 12.6 months. The average body mass index for the cohort was 30.1 ± 5.2. During the 90 postoperative days, the mean length of hospital stay was 4.3 days. There were six cases of postoperative VTE: five patients presented with pulmonary embolism (0.9%) and one patient (0.2%) had deep venous thrombosis with an overall VTE prevalence of 1.1%. No specific single factor could be attributed to VTE occurrence. Using our standardized VTE prophylaxis protocol, our institution was effective at keeping VTE rates low. Additional studies would be beneficial to determine optimal VTE prophylaxis protocols in higher-risk patients, such as those with known clotting disorders.

Staged Immediate Nipple Reconstruction With Tube Flap in Immediate Deep Inferior Epigastric Artery Perforator Flap Breast Reconstruction.

In the setting of immediate breast reconstruction by deep inferior epigastric artery perforator (DIEP) flap, the excessive DIEP flap skin is de-epithelialized and then buried under the mastectomy skin. In this study, by virtue of tube flap technique, we hypothesize that the skin supposed to be abandoned could be transferred to the apex of reconstructed breast mound for nipple reconstruction. A total of 60 female patients were recruited between January 2019 and December 2020. All these patients underwent mastectomy including nipple-areola complex and immediate DIEP flap breast reconstruction. A ladder-shaped pedicled flap was raised from the DIEP flap and rolled into a tube. The free end of tube flap was inset into the future nipple position of the reconstructed breast mound 1 week later. After revascularization for 1 month, we divided the previous pedicle and used the tube on the apex of the breast mound to recreate a new nipple. All reconstructed breasts and nipples survived well postoperatively. The average nipple projection was 12.5 ± 2.0 mm immediately after the surgery, which gradually decreased to 9.4 ± 1.5 mm at 1-year follow-up, with the projection loss from the initial measurement as 24.9% ± 1.8%. In total, 51 patients considered the overall impression of breast and nipple reconstruction to be very good or good. We provided an ideal technique that could improve the maintenance of reconstructed nipple projection and have aesthetically acceptable outcomes, without DIEP flap tissue loss, breast mound distortion, or additional scars.

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

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. 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. 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. 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.

Comparison of complications and functional outcomes following total or subtotal glossectomy with laryngeal preservation using a deep inferior epigastric artery perforator free flap versus a rectus abdominis musculocutaneous free flap

ObjectiveWide defects resulting from subtotal or total glossectomy are commonly reconstructed using a bulk flap to maintain oral and speech functions. The flap, including muscle tissue, diminishes with time. This study aimed to compare the surgical outcomes of deep inferior epigastric artery perforator and rectus abdominis musculocutaneous free flap reconstructions after glossectomy with laryngeal preservation. MethodsMedical records of 13 and 26 patients who underwent deep inferior epigastric artery perforator and rectus abdominis musculocutaneous free flap reconstructions, respectively, from 2014 to 2022 at our institution were reviewed. Patients who underwent middle pharynx resection except for the base of the tongue, mandibular bone resection, and sensory reinnervation were excluded. ResultsThe rectus abdominis musculocutaneous groups showed a higher number of lymph node dissection and shorter operative time than the deep inferior epigastric artery perforator groups. No significant differences in postoperative complications or functional oral intake scale scores at 6 months were observed. Volumetric changes on computed tomography images at 6 and 12 months were significantly lower in the deep inferior epigastric artery perforator group. Cancer recurrence was significantly associated with reduced oral function. ConclusionOral function in patients with cancer is influenced by various other factors. However, the deep inferior epigastric artery perforator flap may be suitable for tongue reconstruction because of the minimal postoperative changes in flap volume, easy adjustment of flap thickness, elevation of multiple flaps, and minimal complications at the donor site.

DIEP Donor Site Satisfaction between Patients with and without History of Pregnancy.

With the success of free autologous breast reconstruction, the abdominal donor site is now an important consideration, especially in patients of childbearing age. In our institution, there are increasing patients who have successfully undergone the deep inferior epigastric artery perforator (DIEP) flap despite previous pregnancy. This study aims to answer questions on the effect of the donor site on pregnancy and vice versa. A retrospective cohort study was conducted to identify breast cancer patients who received a free DIEP flap for breast reconstruction from January 2018 to August 2020. Patients were allocated to two groups according to whether they had prior pregnancies with successful deliveries. Demographics, flap-related parameters, surgical outcomes on breast and abdomen, and patient-reported outcome (Breast-Q questionnaire) were analyzed. Patients were excluded if follow-up time was less than 1 year, or if there was incomplete medical records or Breast-Q replies. Ninety-nine of 116 patients had had successful pregnancies with delivery, 17 of them remained nulliparous. No statistically significant differences existed between groups regarding demographic data, flap-related parameters, surgical outcomes on breast and abdomen. Nulliparous patients exhibited significantly lower score in physical well-being in the abdomen domain compared with delivery-experienced patients (62.1 vs. 73.4, p = 0.025). Significantly, nulliparous patients felt more tightness and pulling of the abdominal wall than the delivery-experienced patients (2.9 vs. 3.7; p = 0.05 and 3.5 vs. 4.0; p = 0.04). Free DIEP flap can be transferred safely in nulliparous patients despite a slight increase in abdominal tightness and abdominal pulling. Precise flap design and surgical approaches may help to minimize the abdominal discomfort especially on young, normal body mass index, and nonchildbearing patients.

Anatomical features of a crossing vein connecting left and right internal mammary veins: A preliminary study with computerized tomography or magnetic resonance imaging.

In breast reconstruction with free flaps, retrograde venous anastomosis into the internal mammary vein (IMV) is often unavoidable. Utility of a crossing vein between the right and left IMV, one of the anatomical foundations which make retrograde flow possible, has been reported but only with a few detailed features. This study evaluated the presence, actual location, and diameter of the crossing veins using preoperative imaging such as contrast-enhanced computed tomography (CECT), or contrast-enhanced magnetic resonance imaging (CEMRI). Moreover, this is a preliminary non-invasive study to clarify these processes on a larger scale. We included 29 cases of unilateral breast reconstruction performed between July 2018 and September 2023 at our institution using unipedicled or bipedicled free deep inferior epigastric artery perforator (DIEP) flaps with retrograde venous anastomosis to only one IMV at the level of anastomosis. No congestion or necrosis was observed. In the final 24 cases with sufficient imaging coverage of preoperative contrast-enhanced images (15 CECT and 9 CEMRI), the crossing veins of IMVs were detected and the number, localization, and diameter were measured. In 20 cases of 24 images, the crossing veins between IMVs were completely identified (83%). In 18 of the cases, only one crossing vein was established immediately ventral to the xiphoid process, averaging 19.3 ± 7.18 mm caudal to the fibrous junction between the sternal body and xiphoid process. The average diameter of the veins was 1.57 ± 0.42 mm. In two other cases, the second crossing vein originated on the dorsal surface of the sternum, but it was a very thin vein of about 0.4 mm. Three images indicated incomplete identification of the crossing vein at the xiphoid process, and in one case, no crossing vein was observed between bilateral IMVs. The contrast-enhanced imaging study revealed an anatomic feature that the crossing veins (about 1.5 mm in diameter) connecting the right and left IMVs are located just ventral to the xiphoid process. Furthermore, the crossing veins can be identified on contrast-enhanced images, and refinement of this method is expected to lead to future non-invasive anatomical investigations in an even larger number of cases.

Evaluating the utility of CT angiographic reports for evaluation of deep inferior epigastric artery in preparation for DIEP flap breast reconstruction surgery

Evaluating the utility of CT angiographic reports for evaluation of deep inferior epigastric artery in preparation for DIEP flap breast reconstruction surgery

Pre-expanded thin DIEP free flap in pediatric upper extremity reconstruction for burn sequelae: A case report

Deep burns sequelae involving the upper limb are challenging even for experienced surgeons, mainly because local reconstructive options and donor sites are often compromised. The use of free flaps for this type of reconstruction remains difficult due to the small recipient vessel diameter and tendency to vasospasm. Moreover, pediatric cases bring the challenge to another level. We present the case of a 13-year-old girl presenting major retractile sequelae of the upper left limb, including complete wrist immobilization combining wrist hyper-extension, ulnar deviation deformity, and a ulno-carpal dislocation. She was referred to our department where a two-stage reconstruction was performed using a pre-expanded free deep inferior epigastric artery perforator (DIEP) flap. The first surgery consisted of placing two kidney-shaped expanders in a subfascial plane in the hypogastric region. Four months later, after a bi-weekly expansion, an excision of the scar tissue, and the DIEP flap transfer were completed. At the 12-month follow-up evaluation, both aesthetic and functional results were satisfactory, with a good contour and regained mobility of the wrist.

Safety of Combined Deep Inferior Epigastric Artery Perforator Flaps and Gynecologic Procedures

Safety of Combined Deep Inferior Epigastric Artery Perforator Flaps and Gynecologic Procedures

Using a Microsurgical Robotic Platform for In-flap Anastomosis in Autologous Bipedicular Breast Reconstruction.

Autologous microsurgical breast reconstruction has become a standard of care. As techniques become more individualized and aim for less-invasive approaches, vessels ever smaller in diameter are considered for flap anastomosis. Robot-assisted surgery has great potential to reduce tremor and enhance precise motion. The Symani Surgical System (Medical Microinstruments, Inc., Wilmington, Del.) is a robotic platform designed for microsurgery. It was used for a microsurgical in-flap anastomosis of a bipedicular deep inferior epigastric artery flap for unilateral breast reconstruction. The procedure included fully robot-assisted anastomoses with significant size mismatches using a 3D-exoscope for magnification. Arterial and venous anastomoses were entirely robot-assisted completed in 23 minutes (seven stitches) and 28 minutes (eight stitches) using 9/0 nylon sutures. The intra- and postoperative course was uneventful. This robotic platform facilitates in-flap anastomoses of small vessels by increasing the precision of instrument handling and eliminating tremor. The combination of robotic platforms and exoscopes provides superior ergonomics in comparison with conventional (super)microsurgery. We expect robotic platforms to play a significant role in modern microsurgical breast reconstruction.

Patient-Reported Abdominal Morbidity Following Abdomen-Based Breast Reconstruction.

Abdominal wall morbidity occurs with increased frequency following flap harvest in the obese abdomen. Its impact on patient-reported outcomes (PROs) in breast reconstruction has been poorly characterized. A retrospective review of obese patients undergoing abdominal-based free autologous breast reconstruction was conducted over 15 years. Patient operative characteristics were recorded and outcomes were analyzed. PROs were assessed using the BREAST-Q abdominal survey. In total, 75 women (108 flaps) with the mean body mass index (BMI) of 33.2 were included. Flaps included deep inferior epigastric artery perforator (24%), muscle-sparing (43%), and free transverse rectus abdominis myocutaneous flaps (f-TRAM; 33%). World Health Organization (WHO) obesity class, BMI, and flap type did not affect flap failure (1%) or complication rates. Hernia developed in 7%; all necessitated repair. Eight percent developed abdominal bulge; one was repaired. Hernia formation was associated with increased patient age (p < 0.05). Bulge formation occurred more often in f-TRAM donor sites (p = 0.005). BMI, WHO class, flap type, and mesh use were not related to hernia or bulge occurrence in either univariate or multivariate analysis. The survey response rate was 63%. Abdominal Physical Well-Being (proxy for abdominal wall function) and Satisfaction with Abdomen (patient-perceived cosmesis) were similar across flap types, age, and WHO classification groups. Patients with postoperative bulge reported higher abdominal physical well-being scores, regardless of flap type (p < 0.01). Bulge was correlated with lower satisfaction (p < 0.05). The incidence of abdominal wall morbidity following abdominal free-tissue transfer for breast reconstruction was acceptably low in our population of obese patients. Hernia was a clinically significant complication, warranting surgical repair. Bulge was primarily a cosmetic concern and did not detract from patient-reported abdominal wall function. Age may represent an independent risk factor for hernia formation in this population.

Pedicle stabilization with fibrin sealant in DIEP flap breast reconstruction.

Microsurgical procedures are nowadays routinely performed worldwide in reconstructive surgery. The deep inferior epigastric artery perforator (DIEP) flap has become the gold standard in breast reconstruction due to its excellent outcomes and lower donor site morbidity. However, complications, including flap failure, still occur in DIEP flap breast reconstruction. Often, according to our experience, these complications result from pedicle disorders, which can be attributed to postoperative mobilization. In the present study, we evaluated the efficacy and safety of using a fibrin sealant as a method for pedicle stabilization to prevent pedicle mobilization in the postoperative period. With our technique, after the flap insetting and microsurgical anastomosis, the pedicle was stabilized by applying a fibrin sealant (TISSEEL™) around and over the entire pedicle. Our study included a homogeneous series of 70 patients who received a delayed DIEP flap breast reconstruction. A retrospective study was conducted to evaluate this novel technique compared to the conventional method. In our experience, the fibrin glue allowed us to reduce the strain for correct pedicle positioning and all subsequent efforts to avoid displacements in the postoperative period. Our preliminary results suggest that this method may lead to a reduction in overall complications attributable to pedicle disorders.

Observing vessel stumps axially: A novel exoscope for end-to-end microvascular anastomosis

Although many free tissue transfers have been performed, free flap loss can still occur because of vascular compromise. To facilitate microsurgery, we invented the axial-view microscope (aMS), a new type of microscope that can axially visualize vessel stumps. The aMS was combined with an optical microscope, the so-called bird’s-eye-view microscope (bMS). Using our aMS, we observed the cross-sections of the following 12 arteries during vascular anastomosis: three deep inferior epigastric arteries, three suprathyroid arteries, two thoracodorsal arteries, two jejunal arteries, one lateral circumflex femoral artery, and one facial artery. For each artery, we measured the vessel height-to-width (H–W) ratio to determine the roundness of the vessel stump. Based on the aMS and bMS, the average H–W ratios were 0.877 ± 0.187 and 0.445 ± 0.172, respectively. The H–W ratio obtained using the aMS was significantly higher than that of the bMS (P < 0.001). Providing the surgeon with a bidirectional view of the vessel stump reduced blind spots at the anastomotic site. In this report, we describe our new microscope and associated clinical cases.

The Full Continuum of Robotic Breast Surgery: Robotic-assisted Mastectomy, Robotic DIEP Flap, and Robotic Supermicrosurgery

Summary: In recent years, robotic surgery has rapidly expanded to improve surgical outcomes in a variety of surgical subspecialties. Although plastic surgery has taken longer to integrate robotic surgery into practice, the advantages of robotic-assisted surgery, including improved visualization and resolution, minimally invasive approaches, and the ability to surpass human precision and scale, have driven its more recent adoption into plastic surgery. Currently, procedures performed with robotic assistance that are considered part of the continuum of surgical treatment of breast cancer include robotic-assisted nipple-sparing mastectomy, reconstruction with the robotic latissimus dorsi flap or the deep inferior epigastric artery perforator flap, and robotic microsurgery for the flap anastomosis and/or the surgical treatment of lymphedema. The authors provide an overview of robotic surgery and how it has been integrated into the field of plastic surgery, as well as a review of the most common procedures within the field where robotic assistance can be incorporated: nipple-sparing mastectomy, robotic latissimus flap, robotic deep inferior epigastric artery perforator flap breast reconstruction, and microvascular anastomoses.

DIEP Flap for Head and Neck Reconstruction: An Underutilized Option!

Background The deep inferior epigastric artery perforator (DIEP) flap is a workhorse flap for breast reconstruction. Its use for head and neck (HN) reconstruction is rare. Abdomen provides a donor site abundant in skin and subcutaneous tissue, amenable to primary closure; sizeable, robust, and consistent perforators and a long, sizeable pedicle for comfortable microvascular anastomosis. Its offers all the donor variables needed for HN reconstruction in abundance. Methods It is a quasiexperimental design study. DIEP flap use for HN reconstruction in our series was opportunistic, that is, when donor site matched the defect. Cases that had very thick thighs and lesser bulk in abdomen and cases that had very thin thighs but much more bulk in abdomen were considered for reconstruction using DIEP flap. Results The DIEP flap was done in 11 cases for HN reconstruction. There were two re-explorations during postoperative period: one flap loss and another had partial necrosis. Conclusion Abdomen is an excellent donor site option for HN reconstruction in selected cases, especially when harvested as a perforator flap.

Reconstruction of a septic femoral triangle fistula with a pedicled DIEP flap: A case report and mini-review

Flap-based reconstruction techniques have shown promise in preventing scar contractures and enhancing healing in fold areas by providing vascularized and thick tissue. We report a septic rupture of the superficial femoral artery treated with an arterial allograft and covered with a contralateral pedicled Deep Inferior Epigastric Artery Perforator (DIEP) flap. The patient presented favorable outcomes, including optimal healing at 8 months, with no functional limitation. A literature review also discusses alternative pedicled perforator flaps. These modern techniques present several advantages, including reliability, and can be of great interest in complex vascular surgery cases.

Bilateral Free Deep Inferior Epigastric Artery Perforator Flaps for Reconstruction following Mastectomy in Poland Syndrome Patients.

Poland syndrome is classically described as symbrachydactyly, with hypoplasia of the pectoralis major and other upper thoracic musculoskeletal structures. It is thought to be caused by intrauterine interruption in subclavian arterial flow and often includes breast hypoplasia. Affected vasculature can pose a challenge for reconstruction with free flaps because inflow may not be reliable in this patient population. We present the rare case of a 28-year-old woman with left-sided Poland syndrome, significant family history of breast cancer, and BRCA1+ mutation who underwent bilateral prophylactic nipple-sparing mastectomies with successful immediate bilateral deep inferior epigastric artery perforator free flap reconstruction. The surgical literature in this clinical scenario is also reviewed. Preoperative computed tomography angiography of the chest successfully demonstrated the patency and quantified the caliber of the internal mammary vessels to support free flap breast reconstruction. Free tissue transfer is a viable option for breast reconstruction in patients with Poland syndrome undergoing mastectomy guided by preoperative computed tomography angiography to characterize the internal mammary vasculature.

Bilateral Perineal Reconstruction Using an Oblique V-shaped DIEP Flap

The reconstruction of soft tissue defects in the peritoneal region after malignant tumor resection is challenging. To reconstruct large defects, primary closure or local flaps are inadequate, and they do not provide cosmetically and functionally good results. The gracilis, gluteal, and rectus abdominis flaps are workhorse flaps for reconstructing large peritoneal defects. Surgical procedures should be carefully chosen on the basis of the size and location of the defect. In this report, we describe two cases of bilateral large defect reconstruction after malignant tumor resection using a V-shaped deep inferior epigastric artery perforator flap. Our procedure is useful as it shows that single flaps can be used to reconstruct large and bilateral peritoneal defects.

Iatrogenic Endometriosis of the Breast Mimicking Fat Necrosis: A Case Report.

A female patient with a history of ductal carcinoma in situ in the left breast, status-post bilateral mastectomy with deep inferior epigastric perforator artery flap reconstructive surgery, presented with a right breast asymmetry concerning for fat necrosis. Histological analysis revealed the presence of benign glands and associated stroma within fibroadipose tissue, confirmed as endometriosis by immunohistochemical analysis. Further investigation revealed that the patient had a previous diagnosis of endometriosis associated with a cesarean section scar that likely seeded the ectopic endometrial glands into a tertiary site by utilizing abdominal tissue that may have harbored endometriosis.

Transforming breast reconstruction: the pioneering role of artificial intelligence in preoperative planning.

Autologous breast reconstruction surgery is a vital part of the recovery process for patients with breast cancer. While various reconstructive options exist, the deep inferior epigastric artery perforator (DIEP) flap is often favoured for its ability to closely mimic natural breast tissue. However, the complex vascular anatomy associated with the deep inferior epigastric artery (DIEA) presents challenges for surgeons during DIEP flap execution. Preoperative imaging, such as computed tomography angiography (CTA), is commonly used to understand vascular architecture and aid in selecting appropriate perforators. Conventional reporting of CTA scans is a labour-intensive process that can be challenging and requires specific expertise. The integration of artificial intelligence (AI) and machine learning (ML) algorithms in medical imaging has the potential to address these challenges. AI can enhance CTA through improved data acquisition, image post-processing, and potentially interpretation. By automating the perforator selection process, AI applications can significantly reduce the time spent on preoperative imaging analysis and potentially improve accuracy and reliability. While AI shows promise in optimizing efficiency, accuracy, and reliability in breast reconstruction planning, challenges and ethical considerations need to be addressed. This article explores the challenges, opportunities, and future directions of using AI in the preoperative planning of autologous breast reconstruction.