Deep Inferior Epigastric Flap Research Articles

A Safe and Efficient Technique for Pedicled TRAM Flap Breast Reconstruction.

After studying this article, the participant should be able to: 1. Understand the indications for a unilateral pedicled transverse rectus abdominis (TRAM) flap-based breast reconstruction. 2. Understand the different types and designs of pedicled TRAM flap used in both immediate and delayed breast reconstruction. 3. Understand the essential landmarks and relevant anatomy of the pedicled TRAM flap. 4. Understand the steps of raising the pedicled TRAM flap, the subcutaneous transfer, and the insetting of the flap on the chest wall. 5. Understand the nature of donor-site management and closure of the defect. 6. Develop a postoperative plan for continuing care and pain management. This article focuses primarily on the unilateral, ipsilateral pedicled TRAM flap. Although the bilateral pedicled TRAM flap may be a reasonable option in some cases, they have been shown to have a significant impact on abdominal wall strength and integrity. Other types of autogenous flaps using the same lower abdominal tissue, such as a free muscle-sparing TRAM or a deep inferior epigastric flap, can be performed as a bilateral procedure with less impact on the abdominal wall. Breast reconstruction with a pedicled transverse rectus abdominis flap has persisted for decades as a reliable and safe form of autologous breast reconstruction leading to a natural and stable breast shape.

Feasibility and Efficacy of Low Thoracic Ultrasound-Guided Erector Spinae Plane Blocks in Patients Undergoing Radical Total Mastectomy With Deep Inferior Epigastric Perforator Flap Reconstruction.

The analgesic efficacy of bilateral low thoracic erector spinae blocks for combined major breast and abdominal surgery has not been reported. The aim of this case series was to assess the feasibility and efficacy of T8 thoracic preincisional erector spinae blocks in patients undergoing total radical mastectomies with axillary lymph node dissections in addition to reconstruction with abdominal deep inferior epigastric flaps. The aim was to supply dermatomal coverage to provide analgesia for T2-L1 that formed the basis for an opioid-sparing multimodal technique in the context of our early recovery after breast surgery with deep inferior epigastric flap program.

Covering of wound infection in hip arthroplasty with local cutaneous flaps

Total hip arthroplasty is a very common procedure to treat osteoarthritis. One of the complication is the infection which occurs in about 1% of the cases. The manifestation of infection can be poor wound healing with dehiscence and exposition of bone or prosthetic components. Hip arthroplasty infections are difficult to treat. It required an associated multidisciplinary approach with infectiology, orthopedic and plastic surgeries. The study included five patients with hip wound dehiscence after total hip arthroplasty. Coverage after orthopedic surgery was provided by local cutaneous flap. These cutaneous flaps were either a deep inferior epigastric perforator flap (DIEP) or a transposition flap. The orthopedic and the plastic treatment were done at the same time. Two deep inferior epigastric flaps were performed for patients with a deep defect with bone or prosthesis exposure. Four transposition flaps were done in three patients with wound dehiscence but without direct contact with the prosthesis. Three transposition flaps were done from the abdominal wall and one from the posterior thigh. The mean follow up was 18 months, ranging from 10 to 24months. After healing, there was no recurrence of the infection. In all cases, the coverage was obtained. The prosthesis was salvage and the gait was possible. Cutaneous flaps are easy and safe to cover the hip. They are reliable flaps even in patients with multiple co-morbidities. They do not cause sequelae on the recipient site. This study is the first about cutaneous flap for covering hip defects in hip arthroplasty infections.

Free tissue transfer for lower extremity trauma in the pediatric patient

Aim: The utilization of free-tissue transfer secondary to traumatic lower extremity defects in the pediatric population is scarcely described. Factors include microsurgeon inexperience, inadequate center resources, and fear of historically described poor surgical outcomes. The aim of this study is to investigate more recent articles describing free-flap microsurgical reconstruction for these defects. Methods: A systematic review of the literature was conducted through the online databases PubMed, Embase, and Web of Science, examining for articles with at least 20 subjects utilizing free-tissue transfer for soft-tissue defects of the pediatric (aged 18 and younger) lower extremity following traumatic etiology since 2005. Outcomes included flap failure, return to the operating room, and functional status, where available. Results: Seven studies were deemed appropriate for inclusion, with a total of 243 flaps included. Motor vehicle and motorcycle accidents were greater than 75% of total etiology. Most defects involved the foot or ankle (65.1%). In total, perforator flaps compromised the majority of flaps (54%), with the most common being the anterolateral thigh, the scapular/parascapular, and deep inferior epigastric flaps. Less common perforators included the groin flap, tensor fascia lata, radial forearm, lateral arm, and thoracodorsal perforator flap. Muscle-based flaps were less common (46%), with the latissimus dorsi and rectus muscle flaps composing the majority. The most commonly used recipient vessel was the anterior tibialis (49.5%) and posterior tibialis vessels (45.3%). Most studies performed reconstruction within 7-10 days of presentation. There was a cumulative 6.5% flap failure rate. Conclusion: Free tissue transfer for pediatric lower extremity trauma is an important tool that likely leads to powerful outcomes. Recent trends indicate increasing usage of perforator flaps. This study shows that based on existing data, free flap utilization for pediatric patients is an adequate modality for repair, and may warrant greater consideration moving forward.

931 Deep Inferior Epigastric Perforator (DIEP) Flap: Impact of Early Drain Removal on Seroma Formation Rate and Duration of Inpatient Stay

Abstract Aim Donor site seroma can follow deep inferior epigastric flap (DIEP) harvest. Post-surgery gradient technology (GTC) garments are worn by DIEP patients postoperatively following drain removal to reduce seroma formation. Early drain removal was considered a contributing factor to increased seroma formation rate. From June 2018 drain removal regardless of output was instigated at day two post-surgery. Prior to this, drains were removed when less than 30mls over 24 hours. We aim to assess the seroma rate post DIEP harvest with early drain removal. Method Retrospective review of prospectively managed database between June 2018 to May 2020. Surgical complications and length of stay in hospital were recorded. Results 200 patients underwent DIEP flap breast reconstruction. The mean age of patients was 52 years (range 28-73). There was no significant difference in seroma complication rate between those who had drains removed on day 3 compared with day 2 ((1.02% (1/98) vs. (0.98% (1/102); p = 1). The mean length of stay in hospital for the 1st cohort was 3.86 days and for the 2nd cohort was 3.23 days. There were no complications related to drain removal. Conclusions Our data suggests that drain removal after 2 days postoperatively with DIEP reconstruction does not affect seroma complication rates. Moreover, it leads to a shorter hospital stay. These conclusions are in keeping with enhanced recovery protocols and an early drain removal surgical process could be advised.

Consecutive 265 Profunda Artery Perforator Flaps: Refinements, Satisfaction, and Functional Outcomes.

Introduction:The ideal form of breast reconstruction provides total permanent restoration of the breast mound. When a deep inferior epigastric (DIEP) flap is not an option or does not provide significant volume, a secondary source must be considered. In our practice, the profunda artery perforator (PAP flap) from the thigh has emerged as a second choice. We present our experience with the first 265 PAP flaps used for breast reconstruction at our institution. We specifically focus on refinements, satisfaction, and functional outcomes.Methods:We conducted a retrospective review of the first 265 PAP flaps at our institution. Patient demographics, perioperative data, and postoperative complications were recorded and analyzed. The Breast Q and Lower Extremity Functional Scale (LEFS) were both implemented. Additionally, a satisfaction survey was performed, particularly focused on the donor site.Results:Two hundred sixty-five consecutive PAP flaps were used to reconstruct 244 breasts in 138 patients. The PAP flap was used for bilateral reconstruction (107 patients) and unilateral breast (30 patients). It was used in combination with a second flap as double PAP (21 patients) or combined with a DIEP (62 patients). Mean flap size was 403 g (range: 190–800 g) and mean patient body mass index was 26.5 (range: 18–43). Complications included total flap loss (3%), donor site cellulitis (4.9%), and significant donor site wound (6.8%). Currently, the PAP flap accounts for 16.9% of our autologous breast reconstruction and the DIEP flap accounts for 76.0%. Lower Extremity Functional Scale score was 75/80 (94%) by 6 months. Satisfaction with breast reconstruction was 78.9% and satisfaction with the thigh was 82.1%.Conclusions:The PAP flap is an excellent option for autologous breast reconstruction. Success rate and complications are similar to those of other options. There is no significant loss to lower extremity function and satisfaction with the reconstruction is comparable with other options.

Characterizing Nipple Biomechanics: In Search of an Ideal Tissue Substitute

INTRODUCTION: Following total mastectomy, nipple reconstruction is an essential, often last step of breast reconstruction. The positive psychological effect is critical to the recovery process, and patients report increased satisfaction, with increased happiness in sexual behavior and their nude appearance. As is the case for most reconstructive surgeries, use of autologous tissue is the ideal reconstructive methodology, eliminating the possibility of rejection, minimizing infection, and maximizing tissue integration and permanence. Autologous costal cartilage (CC) grafts have been used to maintain neo-nipple projection, but this technique is suboptimal due to difficulty of controlling the size and shape of the neo-nipple and stiff biomechanical qualities of resultant neo-nipple. We have previously shown the efficacy of minced CC in preservation of neo-nipple projection when integrated with external biodegradable scaffold. Herein, we assess simple and reliable methodologies for mechanical processing of CC to achieve desired biomechanical characteristics that mimic the human nipple more closely. METHODS: Excess CC, from patients undergoing deep inferior epigastric flap procedure, was mechanically processed by either shredding or mincing in sterile fashion. Mechanically processed cartilage was either packed into a custom-designed, 3D-printed external scaffolds (made from polylactic acid), or an equal volume was wrapped in Surgicel. The constructs were implanted into nude rats by creating a subcutaneous pocket using CV flap technique. The constructs were explanted after 3 months for histologic and biomechanical testing. Biomechanical testing was also performed on native human nipple and premanipulation/implantation CC. Confined compression testing was performed by compressing the samples to 30% of their original height in 6 steps of 5% strain, with 10 minutes between steps to allow for full stress relaxation. Equilibrium modulus was calculated. RESULTS: After 3 months in vivo, mechanical analysis demonstrated that mincing of the cartilage changed the equilibrium modulus and hydraulic permeability of implants to values closer to native human nipple regardless of presence of the external scaffold. The minced CC possessed almost 4 times smaller modulus than the premanipulation/implantation CC on average (702 versus 2,723 kPa; P = 0.0036). The average human nipple had lower, but not statistically significant, equilibrium modulus than the minced cartilage (257 versus 702 kPa). Hematoxylin/eosin staining and LIVE/DEAD assay showed the presence of healthy and viable cartilage in all groups. There was evidence of fibrovascular tissue invasion resulting in consolidation and incorporation of the implants. CONCLUSIONS: We demonstrate that autologous CC, usually discarded during a deep inferior epigastric flap procedure, can be used as a viable implant for nipple reconstruction. Because the original CC is firm and nonmalleable, mechanical processing of the CC reduces stiffness and allows for incorporation of individualized engineered constructs tailored to patient desire (sizes/levels of projection). We demonstrated that the mincing of CC resulted in constructs with more similar biomechanical properties to that of the native human nipple without the loss of projection or topography seen with traditional approaches to nipple reconstruction.

Comparison of Aesthetic Quality of the Final Scar in Abdominoplasty with Conventional and Mini Inverted t-Scar.

Background and objectives: Abdominoplasty is one of the most commonly performed cosmetic procedures. The excess skin in the conventional abdominoplasty is transversely excised and a single horizontal scar is formed. The mini inverted t-scar abdominoplasty is a modification of the “Fleur-de-lis” technique and involves the use of a small vertical incision in comparison to the long vertical incision. The aim of this technique is to lower the position of the final abdominal scar instead of addressing the horizontal laxity. In this study, we have compared the aesthetic satisfaction, width and the position of the scar with conventional abdominoplasty and mini inverted t-scar abdominoplasty. Materials and Methods: Thirty patients undergoing abdominoplasty and breast reconstruction with transverse rectus abdominis flap (TRAM) and deep inferior epigastric flap (DIEP) were included in the study. In 15 patients, abdominal closure with the conventional transverse scar was performed. In the remaining 15 patients, closure with a mini inverted t-scar was performed. Scar width, scar height and satisfaction scores were evaluated in both groups. Results: Scar widths, scar heights and patients’ and as well as surgeons’ satisfaction scores were better in the mini inverted t-scar group than the conventional group. Conclusions: The visibility of the vertical scar alone should not be a reason to avoid mini inverse t-scar abdominoplasty. Mini inverted t-scar can be an option to achieve a better hidden high-quality scar.

A comparison of long-term cost and clinical outcomes between the two-stage sequence expander/prosthesis and autologous deep inferior epigastric flap methods for breast reconstruction in a public hospital

Postmastectomy breast reconstruction involves the use of large amounts of hospital resources. This study provides comparative data on the clinical results and long-term economic costs of two methods of breast reconstruction in a public hospital. A prospective cohort study was performed to evaluate the costs incurred by delayed unilateral breast reconstruction performed using either the two-stage sequence expander/prosthesis (E-P) or autologous deep inferior epigastric flap (DIEP) method during 2005-2013 in 134 patients. The major evaluated variables included previous clinical records, history of radiotherapy, and number of surgical procedures. Total costs accounted for both direct intra- and extra-hospital costs derived from the initial reconstruction and those resulting from associated reoperations due to aesthetic retouches and/or complications. Patients undergoing E-P reconstruction required a higher number of surgery sessions to complete the reconstruction (3.07 vs. 2.32, p < 0.001) and showed higher rates of surgery-related complications (40.29% vs. 32.82%). No statistically significant differences were found between the two surgical methods in terms of total costs (€18857.77 DIEP vs. €20502.08 E-P; p = 0.89). In the E-P cohort, active smoking and history of radiotherapy were statistically significant risk factors of complications. In the DIEP group, only active smoking was significantly associated with complications. Compared to the E-P method, breast reconstruction using the DIEP method is more cost-effective and involves fewer serious complications that result in reconstruction failure or undesirable aesthetic results. E-P reconstruction presents a higher number of complications that may cause surgical failure or poor outcomes.

Reconstruction d’une perte de substance de racine de cuisse sur membre lymphœdèmateux par un lambeau DIEP pédiculé

Root thigh extensive loss of substance requires surgical coverage. The presence of chronic lymphedema (LC) makes random with the postoperative healing time longer. We report an original case of reconstruction of extensive loss of substance from the root of the thigh using a pedicled deep inferior epigastric flap perforator (DIEP) flap. A 22-year-old woman with angiosarcoma occurring in hemi-body lymphedema. The defect generated by the oncologic resection was 16×24cm. She was reconstructed by a pedicled DIEP flap. Skin wound healing was obtained within 30 days. Donor site healing was obtained within 15 days. The pedicled DIEP flap seems to be effective for root thigh reconstruction.

A quantitative analysis of the venous outflow of the deep inferior epigastric flap (DIEP) based on the perforator veins and the efficiency of superficial inferior epigastric vein (SIEV) supercharging

While the arterial perfusion of the anterior abdominal wall has been extensively described in the literature, little has been published on the venous drainage of the deep inferior epigastric flap (DIEP). The present study was performed to further clarify the venous drainage of DIEP flap, which remains a common vascular complication of this flap. We assessed the efficiency of venous outflow on 19 patients undergoing DIEP flap breast reconstruction, determining relative haemoglobin concentration (rHB) as an indicator of venous congestion. After the flap had been isolated on the perforator vessels, a selective clamping and declamping of the single lateral and medial perforator was performed and several measurements were carried out using a micro-lightguide spectrophotometer device (O2C: Oxygen to See; LEA Medizintechnik, Gießen, Germany). In addition, the efficacy of venous supercharging with ipsilateral and contralateral superficial inferior epigastric veins (SIEVs) was quantified. For the sake of simplicity, we applied the classic perfusion zones of the lower abdomen as suggested by Hartrampf (1983). Regardless of lateral or medial DIEP perforator veins, zone IV showed the least venous outflow, while we observed the highest drainage in zone I. There was no significant difference between the venous drainage of the two immediately adjacent zones II and III. Supercharging with the contralateral SIEV showed a significantly better venous drainage in the contralateral zones II and IV, whereas the ipsilateral SIEV did not present any significant improvement in the venous drainage of any zone. This study evaluated the characteristics of the venous outflow of the DIEP flap, based on the single perforator and the SIEVs. Our findings revealed that zones II and III have a similar venous drainage regardless of the perforator veins used. The supercharging of the contralateral SIEV leads to an improved venous outflow compared to the ipsilateral SIEV. This may support surgeons in minimising venous complications and may improve the degree of DIEP flap survival.

Total or subtotal glossectomy with microsurgical reconstruction: Functional and oncological results

Management of patients after total or subtotal glossectomy presents challenging reconstruction of complex three-dimensional defects. Such defects can have a dramatic effect on respiration, speech, and nutrition, and may significantly impact quality of life. We present our experience with 39 patients submitted to total or subtotal glossectomy and reconstruction with microsurgical flaps. Functional results are reported in term of swallowing ability, decannulation, and intelligible speech. Oncological outcomes are described in terms of local disease control and overall survival rate. We carried out 24 total glossectomies and 15 subtotal glossectomies. Total glossectomy was associated with a total laryngectomy in eight patients. Reconstruction was performed using Taylor's myocutaneous extended deep inferior epigastric flap in 33 patients, and an anterolateral thigh perforator flap in six patients. A fibula osteocutaneous free flap was raised in two patients with an anterior segmental mandibulectomy. A second free flap was needed in three cases. Wound complications occurred in 17 patients: an orocutaneous fistula in eight patients and a dehiscence of the suture without fistulization in nine patients. Oral feeding was resumed in 33 patients (85%). In nonlaryngectomized patients, decannulation was achieved in 28 (90%) and speech was good or acceptable in 27 (87%). The 5-year adjusted survival for patients treated with total or subtotal glossectomy was 47%. Our results in a relatively large sample of patients who underwent total or subtotal glossectomy followed by reconstruction with microsurgical free flaps support the efficacy of this surgery as treatment for advanced oral and oral pharyngeal cancers.

Free flap transplantation in the reconstruction of large area defects in head and neck

Objective To review clinical experience of free flap transferring in the reconstruction of head and neck defects. Methods Fifteen free anterolateral thigh flaps, 5 free deep inferior epigastric flaps and 3 free lateral arm flaps were used to reconstruct large area head and neck defects. Results All 23 free flaps were alive with good appearance. 1 case survived by performing embolectomy after suffering arterial crisis and delayed recovery of wound took place in 2 cases. Conclusion Free flap transplantation is an ideal choice for reconstructing large area cranio-facio-cervical defects. Key words: Head and neck; Free flap; Transfer; Microsurgical operation

Deep Inferior Epigastric Perforator Flap for Successful Simultaneous Breast and Chest Wall Reconstruction in a Poland Anomaly Patient

Breast reconstruction in female Poland anomaly remains a surgical challenge with variable chest wall deformity and nipple position. Pedicled latissimus dorsi myocutaneous flap with implant reconstruction may have several drawbacks and complications. Free deep inferior epigastric flap (DIEP) flap is a reliable option for postmastectomy breast reconstruction, but rarely reported in Poland anomaly. We presented a 52-year-old Poland anomaly patient who underwent successful reconstruction for breast and chest wall deformity using DIEP flap. Preoperative ultrasound Doppler study for internal mammary vessels is recommended for microsurgical anastomosis. Care should be taken with regard to the flap inset and the location of the nipple areolar complex.

A deep inferior epigastric flap with a prefabricated thin portion obtained from the insertion of a silicone sheet

The rectus abdominis flap has been widely utilised but a disadvantage is that the flap is rather thick. We have succeeded in preparing a stable thin flap in obese patients. This has been achieved through prefabrication by the subcutaneous insertion of a silicone sheet adjacent to a conventional deep inferior epigastric flap.

A method of phalloplasty using the deep inferior epigastric flap

Penile reconstruction remains a difficult surgical problem. To produce a phallus capable of erection and with a water-tight urethra to the tip has not been solved satisfactorily even by the introduction of free flap transfers. We present a method used in four cases, three transsexuals and one pseudohermaphrodite, in which a phallus was successfully constructed using the deep inferior epigastric flap.

The extended deep inferior epigastric flap: a case report

The extended deep inferior epigastric flap, described by Taylor et al. (1983), 1984), offers a versatile and reliable technique for covering defects in the lower limb. A case of shark bite is described in which extensive soft tissue loss in the thigh resulted in a denuded femoral shaft which was successfully treated using such a flap.