Deep Inferior Epigastric Artery Flap Research Articles

No Skin Paddle, No Problem: Burying Deep Inferior Epigastric Artery Flaps in the Immediate Setting is Safe in Select Patient Populations.

In appropriately selected patients, it may be possible to fully bury breast free flaps deep to the mastectomy skin flaps. Because this practice forgoes the incorporation of a monitoring skin paddle for the flap, and thus limits the ability for physical exam, it may be associated with an increased risk of flap loss or other perfusion-related complications, such as fat necrosis. We hypothesized that fully de-epithelialized breast free flaps were not associated with an increased complication rate and reduced the need for future revision surgery. A single-institution retrospective review of 206 deep inferior epigastric artery (DIEP) flaps in 142 patients was performed between June 2016 and September 2021. Flaps were grouped into buried or nonburied categories based on the absence or presence of a monitoring paddle. Patient-reported outcomes were assessed postoperatively using the BREAST-Q breast reconstruction module. Electronic medical record data included demographics, comorbidities, flap characteristics, complications, and revision surgery. The buried flap patients (N = 46) had a lower median body mass index (26.9 vs 30.3, p = 0.04) and a lower rate of hypertension (19.5 vs. 37.5%, p = 0.04) compared with nonburied flap patients (N = 160). Burying flaps was more likely to be adopted in skin-sparing mastectomy or nipple-sparing mastectomy (p = 0.001) and in an immediate or a delayed-immediate fashion (p = 0.009). There was one flap loss in the nonburied group; complication rates were similar. There was a significantly greater revision rate in the nonburied flap patients (92 vs. 70%; p = 0.002). Buried flap patients exhibited a greater satisfaction with breasts (84.5 ± 13.4 vs. 73.9 ± 21.4; p = 0.04) and sexual satisfaction (73.1 ± 22.4 vs. 53.7 ± 29.7; p = 0.01) compared with nonburied flap patients. Burying breast free flaps in appropriately selected patients does not appear to have a higher complication rate when compared with flaps with an externalized monitoring paddle. Furthermore, this modification may be associated with a better immediate aesthetic outcome and improved patient satisfaction, as evidenced by a lower rate of revision surgery and superior BREAST-Q scores among buried DIEP flaps.

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.

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.

Streamlining and Consistency in Surgery: Lean Six Sigma to Improve Operating Room Efficiency.

Improving perioperative efficiency helps reduce unnecessary surgical expenditure, increase operating room throughput, improve patient safety, and enhance staff and patient satisfaction. Lean Six Sigma (LSS) is a quality improvement model that has been successfully applied to eliminate inefficiencies in the business sector but has not yet been widely adopted in medicine. This study investigates the adaptation of LSS to improve operative efficiency for plastic surgery procedures. The authors followed the define, measure, analyze, improve, and control phases to implement LSS. The key outcome measures gathered were operative times, including the cut-to-close time, and the total time the patient spent in the operating room. The study included a total of 181 patients who underwent immediate bilateral deep inferior epigastric perforator flap breast reconstruction between January of 2016 and December of 2019. The LSS interventions were associated with a decrease in total operative time from 636.36 minutes to 530.35 minutes, and a decrease in the time between incision to closure from 555.16 minutes to 458.85 minutes for a bilateral mastectomy with immediate deep inferior epigastric artery flap breast reconstruction. This study demonstrates that LSS is useful to improve perioperative efficiency during complex plastic surgery procedures. The workflow of the procedure was improved by determining the optimal spatial positioning and distinct roles for each surgeon and preparing surgeon-specific surgical trays. Two process maps were developed to visualize the positioning of the surgeons during each stage of the procedure and depict the parallel workflow that helped improve intraoperative efficiency.

Preoperative Perforator Mapping in DIEP Flaps for Breast Reconstruction. The Impact of New Contrast-Enhanced Ultrasound Techniques.

Deep inferior epigastric artery flaps (DIEP) represent the gold standard of autologous breast reconstruction. Due to significant variations in vascular anatomy, preoperative perforator mapping (PM) is mandatory in order to ensure the presence of a sufficient perforator within the flap. In this regard, CT angiography (CTA) is currently the method of choice. Therefore, we investigated the value of contrast-enhanced ultrasound (CEUS) techniques for preoperative PM in comparison to CTA. Patients underwent PM, utilizing both CTA and CEUS techniques. Documentation included the course of the vascular pedicle through the rectus muscle (M), fascial penetration (F), the subcutaneous plexus (P) and the skin point (SP) on either side of the abdomen. Thus, contrast-enhanced B-Flow (BCEUS), B-Flow ultrasound (BUS), CEUS, color Doppler ultrasound (CDUS) and CTA were evaluated in terms of the diagnostic consistency and effectiveness of PM. Precision (∆L) was then calculated in relation to the actual intraoperative location. Statistical analysis included Kruskall-Wallis, Levene and Bonferroni tests, as well as Spearman correlations. A total of 39 DIEP flaps were analyzed. Only CTA (∆L = 2.85 mm) and BCEUS (∆L = 4.57 mm) enabled complete PM, also including P and SP, whereas CDUS, CEUS and BUS enabled clear PM throughout M and F only. Regarding the number of detected perforators, PM techniques are ranked from high to low as follows: CTA, BCEUS, BUS, CEUS and CDUS. CTA and BCEUS showed sufficient diagnostic consistency for SP, P and F, while CDUS and CTA had a superior performance for M. BCEUS offers precise image-controlled surface tags and dynamic information for PM without imposing radiation and may, therefore, be considered a feasible add-on or alternative to CTA. However, BCEUS requires an experienced examiner and is more time-consuming.

Breast reconstruction using the profunda artery perforator (PAP) flap: Technical refinements and evolution, outcomes, and patient satisfaction based on 116 consecutive flaps

When a deep inferior epigastric artery flap is not suitable, the profunda artery perforator (PAP) flap can be a good alternative for autologous breast reconstruction. Popularity of the PAP flap is expanding, but it is still only slowly being adopted worldwide. We report our experience with 116 consecutive PAP flaps showing refinements and evolution of the technique towards improvement in outcomes and patients' satisfaction. We prospectively collected data from consecutive PAP flap breast reconstructions performed from 2016 to 2019. Patients' demographics, pre-, intra-, postoperative data, and revision procedures were analyzed. The BREAST-Q and a specific questionnaire investigating outcomes at the donor site were completed preoperatively and 12 months postoperatively. One-hundred and sixteen PAP flaps were performed in 86 patients, 64 unilateral and 22 bilateral breast reconstructions. Mean body mass index was 24.72kg/m2 (range 18.9-29.2) and mean flap weight was 251.30g (range 152-455g). Complications included donor site hematoma (1.7%), seroma (2.6%), fat necrosis (1.7%), and wound dehiscence (2.6%). No arterial/venous thrombosis nor flap losses were recorded. Patients reported high satisfaction in all BREAST-Q domains, with mean postoperative scores being higher than preoperative ones, suggesting a positive effect in quality of life and satisfaction. Scores were significant in the satisfaction with breast domain (p=0.0016). Breast reconstruction with PAP flap yields a high success, low complications, and excellent cosmetic outcomes in the breast and donor sites. It improves patients' satisfaction and quality of life; hence, it can be considered an excellent option for autologous breast reconstruction.

Do medial sural artery perforator flaps have better clinical outcomes compared to the rectus abdominis perforator (DIEAP) flap in reconstruction of glossectomy defects? A Prisma guided meta-analysis.

Background:There is an increasing evidence for the use of thin flaps based on vascular perforators for reconstructive surgeries. The medial sural and deep inferior epigastric artery flaps offer versatility for the reconstruction of major defects of the head and neck.Objectives:“Whether medial sural artery perforator (MSAP) flap or rectus abdominis perforator flap is better for the reconstruction of glossectomy defects in terms of functional outcome?”Data Sources:PubMed, Cochrane Library, clinicaltrials.gov and hand searches.Participants and Interventions:Patients who underwent tongue reconstruction with either MSAP flap or deep inferior epigastric artery perforator (DIEAP) flap.Study Appraisal and Synthesis Methods:Based on defined study criteria 6 studies were selected according to Prisma Guidelines. The overall estimated effect was categorized as significant where P < 0.05.Results:There was no significant difference between both flaps in terms of receptor site complications (P = 0.223). Overall odds ratio (OR) for complications was 1.35 (95% confidence interval [CI]: 0.412–0.736) and the test for overall effect t value was 2.836, P < 0.05. Overall OR was 6.01 (95% CI 0.5–7.45) and the test for overall effect t value was 1.41, P < 0.05 indicating there was a statistical difference in the intelligibility of speech.Limitations:Anatomical variations, under-reporting of studies and lack of universal tool for speech intelligibility.Conclusions and Implications of Key Findings:Both the flaps are comparable in terms of functional outcome. Medium-sized defects can be reconstructed with MSAP and composite larger defects would benefit from DIEAP. In females, anterolateral thigh flap still remains the choice for composite reconstructions.

Alternative Perforator Options for Insufficient Profunda Artery Perforators: A Case and Anatomical Study.

The profunda artery perforator (PAP) flap can be an alternative to the deep inferior epigastric artery flap. However, in some cases, the PAP may not be adequate to perfuse the whole flap. In this study, we describe 3 cases in which an alternative perforator was used for PAP flap perfusion. In addition, we describe an anatomical study to explore the perforasome of the PAP and alternative perforators. Three cases are described in which an alternative perforator was used to successfully perfuse the pap flap. For the anatomical study, 7 PAP flaps were raised from cadavers. Ink was injected in the PAP, the gracilis perforator (GP) and the descending branch of the inferior gluteal artery perforator (DBIGA). Then, perfused area of the flap by each perforator was calculated. The 3 patients with alternative perforators recovered without complications, in addition, no signs of fat necrosis were observed. Concerning the anatomical study, mean perfusion area of the PAP pedicle was 204 ± 90 cm (range, 141-364 cm). The GP and the DBIGA had a perfusion area of 182 ± 42 cm (range, 123-235 cm) and 157 ± 22 cm (range, 136-192), respectively. Although the PAP flap has considerable benefits over the more traditional inferior gluteal artery perforator and transverse upper gracilis flaps, a plastic surgeon might encounter a PAP flap perforator that is not deemed viable for flap perfusion. In these cases, the GP and DBIGA may be suitable "escape" alternatives to complete the reconstruction.

Perforator Free Flap Coverage of Chronic Lower Extremity Ulcers in Patients With Autoimmune Diseases Under Immunosuppression.

Objectives. Lower extremity ulcers are quite common in patients with autoimmune diseases. Due to chronic use of immunosuppressants, these wounds may develop into deeper wounds resulting in exposure of bone or tendon, which in turn may require free tissue transfers for coverage. The author reviewed perforator free flap transfers performed in this group of patients and analyzed the results. Methods. A retrospective review was performed on all patients who underwent perforator free flap transfer for coverage of lower extremity ulcers without trauma, over a 10-year period. Patient demographics, administered immunosuppressants, and flap and donor site complications were analyzed. Results. Twenty-two perforator free flap transfers were performed in patients with autoimmune diseases, including 18 thoracodorsal perforator flaps, 2 anterolateral thigh flaps, and 2 deep inferior epigastric artery flaps. There was no total flap loss, but there was a high rate of partial flap necrosis (40.9%) and wound dehiscence (40.9%). Intake of corticosteroids was significantly associated with postoperative complications (P < .05). Conclusion. As partial loss of flap and wound dehiscence is much more common in this group of patients, treatment may take longer, and a fully informed consent should be obtained preoperatively. Surgeons should not avoid performing perforator free flap transfers in patients with autoimmune diseases under immunosuppression; instead, much more preparation and caution are required.

A Theoretical Model Describing the Dynamics of Venous Flow in the DIEP Flap.

The deep inferior epigastric artery flap is an integral component of autologous breast reconstruction. The technical aspects of performing the flap have been well-established. A prior mathematical model suggested using the largest perforator and concluded that the inclusion of additional perforators may decrease resistance and increase flow, but at the downside of increased tissue trauma. Many complications may result from inadequate venous drainage of the flap and the same mathematical concepts may be applied. We attempt to give a mathematical model, based on the physics of flow and properties of circuits, to explain clinical observations regarding venous drainage of the flap and the complications that may arise. We compare the different possible venous drainage systems of a perforator flap to a complex circuit with multiple resistances. Multiple venous perforators will be represented by resistances in parallel, while the deep and superficial drainage systems will be represented by a complex circuit loop. Drainage of the flap may be optimized through the deep drainage system if the venous perforators are of sufficient size. Inclusion of additional perforators may decrease resistance and enhance drainage. Salvage procedures may be necessary when the venous perforators are insufficient in size or when there are insufficient connections between the deep and superficial systems. A single large sized vessel may provide adequate drainage in most DIEP flaps, while the use of multiple vessels may enhance drainage upon the encounter of smaller vessels. Salvage procedures may be needed to relieve venous congestion as the design of the venous system becomes more complicated.

Assessment of Tissue Perfusion Following Conventional Liposuction of Perforator-Based Abdominal Flaps.

BackgroundThe effect of liposuction on the perforators of the lower abdominal wall has been investigated in several studies. There are controversial results in the literature that have primarily demonstrated the number and patency of the perforators. The aim of this study was to determine the effect of liposuction on the perfusion of perforator-based abdominal flaps using a combined laser–Doppler spectrophotometer (O2C, Oxygen to See, LEA Medizintechnik).MethodsNine female patients undergoing classical abdominoplasty were included in the study. Perforators and the perfusion zones of the deep inferior epigastric artery flap were marked on the patient's abdominal wall. Flap perfusion was quantitatively assessed by measuring blood flow, velocity, capillary oxygen saturation, and relative amount of hemoglobin for each zone preoperatively, after tumescent solution infiltration, following elevation of the flap on a single perforator, and after deep and superficial liposuction, respectively.ResultsThe measurements taken after elevation of the flap were not significantly different than measurements taken after the liposuction procedures.ConclusionsThe liposuction procedure does not significantly alter the perfusion of perforator-based abdominal flaps in the early period. The abdominal tissue discarded in a classic abdominoplasty operation can be raised as a perforator flap and has been demonstrated to be a unique model for clinical research.

When Is the Deep Inferior Epigastric Artery Flap Indicated for Breast Reconstruction in Patients not Treated With Radiotherapy?

It is controversial whether breast reconstruction with a microvascular free flap should be done without restrictions in patients who have not had radiotherapy. Many regard it as too expensive, but some consider it better and more economically advantageous than an implant reconstruction. Databases of publications were searched to find out under what conditions is it suitable to offer a deep inferior epigastric perforator (DIEP) or a transverse rectus abdominis myocutaneous flap to normalize the body's appearance in a woman whose breast(s) had been removed for cancer or to prevent the development of breast cancer. The effect of breast reconstruction with DIEP flaps was analyzed, taking account of the following factors: general satisfaction (quality of life), aesthetic satisfaction (cosmesis), and morbidity. To find out which factors were of potential importance, we recorded age, hypertension, whether scars from previous abdominal surgery were present, microcirculation, whether the patient was overweight or obese, and costs of the procedure. Patients planning to have DIEP flaps should be willing to stop smoking at least 4 weeks before and after the procedure and have a body mass index of less than 30 kg/m to avoid a higher risk of complications. Because of the paucity of papers, it is difficult to recommend one approach over the other when considering general satisfaction, aesthetic satisfaction, and health economics. However, economical long-term outcome is highly dependent on the initial costs of each procedure and the cumulative costs of complications for each reconstruction method. The scientific foundation of assessment of methods of techniques of breast reconstruction is weak. Therefore, it is important that future studies should present more comparable series, highlight the long-term effects in high-quality studies, to provide the patients with optimal results without undue risks and to avoid financial burdens on society.

Patient satisfaction and health‐related quality of life after autologous tissue breast reconstruction

For this study, the authors evaluated early psychosocial adjustments and health-related quality-of-life changes after breast reconstruction. All consecutive patients who underwent breast reconstruction between June 2009 and November 2010 were asked to complete the BREAST-Q, Hospital Anxiety and Depression Scale (HADS), and Impact of Event Scale (IES) questionnaires before surgery and at 3 weeks and 3 months after surgery. A repeated-measures design was used to compare scores between baseline and postoperative time points. Fifty-one of 55 women completed the questionnaires (response rate, 93%). BREAST-Q subscale scores (breast, sexual well being, and psychosocial well being) improved significantly (P < .05) postoperatively. The other subscale scores related to physical well being of the chest and abdomen dropped significantly 3 weeks after reconstruction; and, by 3 months after reconstruction, both scores improved significantly (P < .05). Large effect sizes for improvements in satisfaction, psychosocial well being, and sexual well being were observed (1.88, 1.2, and 1.31, respectively); whereas deterioration in the effect size for abdominal donor site was reported (-1.56). After adjusting for postoperative complications, there were statistically significant changes in BREAST-Q subscale scores. Changes observed on the HADS and IES provided external validation of the findings obtained on the BREAST-Q. The current results suggested that the gains in breast satisfaction, psychosocial well being, and sexual well being after patients undergo either free muscle-sparing transverse rectus abdominis myocutaneous flap reconstruction or deep inferior epigastric artery flap reconstruction are statistically significant and clinically meaningful to the patient as early as 3 weeks after surgery. However, these gains are accompanied by significant deterioration in physical well being of the abdominal donor site.

Ultrasound-Assisted Lipoplasty in Addition to Suction-Assisted Lipoplasty for Perforator Free Flap Thinning

Perforator flaps are routinely used in upper- and lower-extremity reconstruction. Increased usage of these flaps as well as their intraoperative thinning has been described; however, there are limited reports of thinning in the postoperative period. From 2005 to 2010, thinning procedures were performed on 11 patients with 11 flaps. There were six males and five females in this series. Three flaps were deep inferior epigastric artery flaps, six flaps were anterolateral thigh flaps, and two were medial thigh flaps. After the initial microvascular reconstructive procedure, the patient underwent a second procedure where ultrasound-assisted lipoplasty, suction-assisted lipoplasty, flap advancement, and excision were performed. With aggressive, staged thinning procedures, there were no cases of partial or complete flap necrosis. Given the increasing number of perforator flaps being performed for upper- and lower-extremity reconstruction, a larger number of cutaneous flaps will need postoperative thinning. Ultrasound-assisted lipoplasty has been found to be a useful modality in revision of these flaps.

Free DIEAP and SGAP flap breast reconstruction after abdominal/gluteal liposuction

Perforator flaps are widely used in our unit for breast reconstruction. They provide ample tissue with minimal donor site morbidity together with long lasting aesthetic results. Increasing number of patients may have liposuction procedure which may jeopardise areas such as the abdomen and the buttock which are the donor sites for perforator-free flaps in breast reconstruction. Therefore, liposuction has been considered as a relative contraindication of raising perforator flaps. Six patients who had previous liposuction of the donor sites underwent autologous breast reconstruction with perforator-free flaps. Colour Duplex imaging was obtained in all cases preoperatively in order to evaluate the blood supply to the flap and to map the perforators. There were five deep inferior epigastric artery flaps (DIEP) and one superior gluteal artery perforator (SGAP) flap used. Total flap survival was obtained in all cases. Postoperative course was uneventful. Our results showed that raising perforator flaps after liposuction of the donor sites is possible. Preoperative radiological evaluation of the perforators is mandatory for such difficult cases.

‘Extended deep inferior epigastric artery flaps’ for reconstruction after excision of chondrosarcoma sternum

We describe a case of chondrosarcoma of the sternum requiring wide full thickness chest wall excision thereby creating a difficult defect for reconstruction. A mesh was used for support and two extended deep inferior epigastric artery fasciocutaneous flaps were mobilised medially into the defect.

Use of deep inferior epigastric artery flaps for reconstruction of the female genitalia.

Free skin grafts have been the most conventional choice for reconstructing the female genital area after excision of malignant tumours. However, some patients have developed scar contractures, or depressed deformities or ectropion of the mucosal membrane of the urethra or vagina. We discuss here the use of deep inferior epigastric artery (DIEA) flaps. Although the method leaves a scar in the abdominal region, it can be hidden by underwear. We have operated on six patients with satisfactory results.

Perforator flaps--the history of evolution.

This article reviews the recent evolution of perforator flaps. The tie between perforator flaps and skin flaps as well as perforator flaps and musculocutaneous flaps is explained. The paraumbilical perforator flap, the deep inferior epigastric artery flap (DIEP flap), the gluteal artery perforator flap (GAP flap) and various perforator flaps and perforator-based flaps are described in combination with the review of the relevant literature. As a prospect into the future, the technique of "supra-microsurgery" is presented.

Primary reconstruction to avoid wound breakdown following groin block dissection

We report our experience of immediate reconstruction of the groin using the deep inferior epigastric artery (DIEA) myocutaneous flap following 32 consecutive ilioinguinal block dissections for groin metastases in patients with penile carcinoma. All groin wounds healed primarily, resulting in a short postoperative hospital stay. Transferring one or both DIEA flaps did not lead to any significant functional disability.

Bilobe modification of the deep inferior epigastric artery flap for abdominal wall defect reconstruction

A case is reported of a large upper abdominal wall secondary tumour which was excised and the defect closed in a single stage with a combination of a Gortex patch and a bilobe modification of the oblique rectus abdominis musculocutaneous flap.