Deep Inferior Epigastric Perforator Breast Research Articles

Outpatient Prescription Opioid Use following Discharge after Deep Inferior Epigastric Perforator Breast Reconstruction with and without an Educational Intervention.

There is limited evidence for appropriate postoperative opioid prescribing in autologous breast reconstruction. We sought to describe postoperative outpatient prescription opioid use following discharge after deep inferior epigastric perforator (DIEP) breast reconstruction with and without an educational video. Patients undergoing DIEP reconstruction were given a 28-day postoperative pain and medication logbook from August 2022 to June 2023. Our practice implemented an educational video upon discharge on proper opioid consumption. Descriptive statistics on patient characteristics, intraoperative and postoperative opioid consumption, and outpatient prescription opioid use after discharge were compared between the two cohorts. A total of 53 logbooks were completed with 20 patients in the no video cohort and 33 in the video cohort. On average, the days to cessation of opiates was longer in the no video cohort (8.2 vs. 5.1 days, p = 0.003). The average number of oxycodone 5 mg equivalents consumed following discharge was 13.8 in the no video cohort and 7.8 in the video cohort, which was statistically significant (p = 0.01). Overall, the percentage of opioids prescribed that were consumed in the video cohort was 28.3% versus 67.1% in the no video cohort. For patients discharging home after DIEP reconstruction, we recommend a prescription for 12 oxycodone 5 mg tablets. With the use of an educational video regarding proper opioid consumption, we were able to reduce the total outpatient opioid use to 5 oxycodone 5 mg tablets following hospital discharge.

Actigraphy to Evaluate Changes in Physical Activity After Autologous Breast Reconstruction- A Prospective Comparison Study

Background-Early ambulation and return to preoperative (baseline) ambulatory level is protective against postoperative venous thromboembolism. The duration of decreased physical activity after surgery is unknown for most procedures, as surgeons typically estimate physical recovery based on subjective patient reporting.
 Objectives- To quantify the time it takes to return to baseline ambulatory status after breast reconstruction using actigraphy devices.
 Methods- Actigraphy devices were used to evaluate preoperative and postoperative physical activity levels in patients undergoing autologous breast reconstruction at a tertiary care institution. Steps and resting heart rate (HR) were used as metrics of physical activity and physiological state. "Baseline" physical activity was defined by the average daily step count during the 14 days before surgery. "Return to baseline" occurred when the 7-day daily step average was greater than or equal to 95% of their baseline steps. SPSS (version 22.0) was used for analysis.
 Results- From May 2020 to April 2021, 30 patients were enrolled in the study before deep inferior epigastric perforator breast reconstruction. The mean age was 49.2 years and mean BMI was 28.6. This cohort averaged 7918 ± 3271 preoperative steps. Two patients returned to baseline activity by postoperative day 28. In total, 8 patients returned by postoperative week 8. Preoperative resting HR average was 73.4 ± 9.33 beats per minute. Actigraphy data demonstrated an initial decrease in activity,increase in sleep variability and increased heart rate that approached the patients’pre-operative normalized data as they recovered over time.
 
 Conclusions:These data demonstrate that actigraphy data would be of interest topatients making breast reconstruction decisions and that the data can be successfullycollected to inform decision-making. These findings indicate that surgeons may underestimate the impact of surgery on physical decline and, consequently, may undertreat with venous thromboembolism prophylaxis.

Development and Evaluation of a Remote Patient Monitoring System in Autologous Breast Reconstruction.

Background:Flap monitoring after a deep inferior epigastric perforator flap breast reconstruction is crucial to detect complications in time. A novel and innovative wireless device has been developed and tested in a feasibility study. This study describes our experience with remote patient monitoring via this device in postoperative monitoring of deep inferior epigastric perforator flaps.Methods:Following a deep inferior epigastric perforator breast reconstruction, the “Free Flap Patch” was adhered to the flap, continuously measuring temperature and tissue saturation. Data were stored locally on the patch and analyzed in a retrospective manner. Raw analog-digital-conversion values from the red- and infrared sensors, delta muscle saturation (dSmO2), and estimated tissue oxygenation (StO2) were assessed and compared with clinical records.Results:No adverse events related to the device were recorded. One patient suffered flap loss; a decrease in estimated tissue oxygenation was measured with the device in situ. No deviations in clinical variables were recorded in the uncompromised flaps.Conclusions:A wearable patient monitoring device was successfully utilized in clinical practice. In one patient, a flap failure was recorded where the PPG-derived StO2 parameter was indicatory for this event. The Free Flap Patch has the potential of automatically predicting blood supply issues in an early stage. More data are needed for clinical validation.

Actigraphy to Evaluate Changes in Physical Activity After Autologous Breast Reconstruction.

Early ambulation and return to preoperative (baseline) ambulatory level is protective against postoperative venous thromboembolism. The duration of decreased physical activity after surgery is unknown for most procedures, as surgeons typically estimate physical recovery based on subjective patient reporting. This study aims to quantify the time it takes to return to baseline ambulatory status after breast reconstruction using actigraphy devices. Actigraphy devices were used to evaluate preoperative and postoperative physical activity levels in patients undergoing autologous breast reconstruction at a single academic institution. Steps and resting heart rate (HR) were used as metrics of physical activity and physiological state. "Baseline" physical activity was defined by the average daily step count during the 14 days before surgery. "Return to baseline" occurred when the 7-day daily step average was greater than or equal to 95% of their baseline steps. Study participation was considered complete once a patient returned to baseline or surpassed 8 postoperative weeks. From May 2019 to April 2020, 17 patients were enrolled in the study before deep inferior epigastric perforator breast reconstruction. The mean age was 48.2 years and mean BMI was 27.6. This cohort averaged 7908 ± 3271 preoperative steps. Two patients returned to baseline activity by postoperative day 28. In total, 8 patients returned by postoperative week 8. Preoperative resting HR average was 73.5 ± 9.43 beats per minute. The average resting HR was elevated by 2.59%, 4.28%, and 2.31% at weeks 1, 2, and 3, respectively. The 7-day daily average resting HR had normalized by week 4. Return to baseline physical activity after surgery may take longer than previously perceived, particularly after physiologically demanding surgeries, such as free flap breast reconstruction. These findings indicate that surgeons may underestimate the impact of surgery on physical decline and, consequently, may undertreat with venous thromboembolism prophylaxis.

Five Steps to Internal Mammary Vessel Preparation in Less than 15 Minutes

Sir: We commend the authors on describing steps to improve efficiency in rib harvest for deep inferior epigastric perforator breast reconstruction.1 Their video demonstrates rapid dissection of the internal mammary vessels with a rib removal technique. The case appears to be a nonirradiated chest with virgin tissues. We would like to highlight some points of the technique described that may save time and avoid serious complications. This is particularly the case in an irradiated or previously infected wound bed. We start by splitting the pectoralis major in line with its fibers; however, we raise the muscle both inferiorly and superiorly in a subpectoral plane, taking care to preserve internal mammary artery perforators. In some cases, if a sizable internal mammary artery perforator is present, there is no need to perform a rib removal, and this should save precious surgical time. Another approach that we have used—particularly if there is a large rib space—is the rib-preserving approach (Fig. 1); careful lateral-to-medial dissection with bipolar cautery can be used to identify the vessels. This technique has a learning curve but has potential advantages, such as reduced pain, lower chance of chest wall contour deformity, and faster dissection.2Fig. 1.: Rib-preserving approach.Once the third rib is exposed, the pectoralis major muscle is dissected superiorly and inferiorly. Good exposure is achieved with a deep retractor, stay sutures,3 or fish hook retractors. Like the authors, we split the perichondrium and start dissection with an Obwegeser elevator; if the plane is not clear because of irradiation or previous infection, we use a finer instrument such as a Mitchell trimmer to develop a clear plane and release the adherent posterior perichondrium. This helps develop a natural plane behind the rib, avoiding bleeding and subsequent loss of time (Fig. 2).Fig. 2.: Careful dissection of irradiated scarred tissues of posterior perichondrium with a Mitchell trimmer.Right- and left-handed cardiac Doyen rib elevators are also useful in speeding up rib removal, but care must be taken to first remove all of the posterior perichondrium. Once the rib is dissected free, it is cut on the lateral side with protection from the Doyen rib elevator. If this has been performed carefully, one can disarticulate rib from the sternal joint in one go. We would caution (particularly the less experienced) against use of rongeurs to remove the rib piecemeal in the irradiated chest. The pulling motion to remove the rib can cause avulsion of underlying adherent scarred tissues, which may in turn lead to a hole in the recipient vessels. We use rongeurs only if the disarticulation is incomplete medially. Finally, we must highlight that care must be taken around the dissection of the vein, as it can easily become attenuated, with damage to the vessel wall. We would advise the use of bipolar cautery rather than monopolar that was demonstrated in the video when close to the vessels. In the many units where we have trained, two microsurgical reconstructions are still possible using the additional techniques described. DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication. Mohammed Farid, M.R.C.S., M.Sc.Onur Gilleard, F.R.C.S.(Plast.)Dariush Nikkhah, M.Sc., F.R.C.S.(Plast.)Barts Health NHS TrustThe Royal London HospitalWhitechapel, London, United Kingdom

The drain game: Abdominal drains for transverse rectus abdominis myocutaneous breast reconstruction

We recently published data for the duration of donor site drain use in latissimus dorsi and deep inferior epigastric perforator breast reconstruction, due to a reported requirement in the literature; evidence is still required for transverse rectus abdominis myocutaneous (TRAM) reconstruction. To compare inpatient hospital stay, drainage parameters and donor-site complications associated with closed suction abdominal drain removal by post-operative day (POD) 3 regardless of output (early group), versus after POD 3 where instructions were by drainage volume/24h±output consistency (late group), in post-mastectomy TRAM breast reconstruction. A retrospective review of TRAM breast reconstructions, between June 2008-2013, was undertaken with a minimum 1 year follow-up per patient. Of 65 patients who underwent TRAM breast reconstruction, 56 hospital records contained complete documentation. Both the late (n=35) and early (n=21) drain removal group were matched for age and number of donor site drains (2perpatient). Mean drain removal day (5.34±0.20days vs. 2.67±0.14days; p<0.0001), total drainage (797.86±77.15 mls vs. 295.71±29.72 mls; p<0.0001) and hospital inpatient stay (7.46±0.29days vs. 6.09±0.32days; p=0.003) were greater for patients in the late versus early group. There were no differences in total complications (5.71%(2/35) vs. 14.29%(3/21); p=0.28), including seroma (2.86%(1/35) vs. 4.76%(1/21); p=0.71) rates between the late and early groups. These data suggest significant advantages for patients who have abdominal drains removed early by POD 3, without increased post-operative complications including seroma rates; these data are in keeping with our LD data. We recommend drain removal by POD 3.

The drain game: Abdominal drains for deep inferior epigastric perforator breast reconstruction

The drain game: Abdominal drains for deep inferior epigastric perforator breast reconstruction

The drain game: Abdominal drains for deep inferior epigastric perforator breast reconstruction

The deep inferior epigastric perforator (DIEP) flap is often preferred for breast reconstruction as it allows for autologous reconstruction with less donor site morbidity versus transverse rectus abdominis myocutaneous (TRAM) flap reconstruction. Our group has presented and published data for the duration of donor site back drain use in latissimus dorsi (LD) flap breast reconstruction due to insufficient evidence and a requirement for further investigation in the literature; this evidence is still lacking for DIEP reconstruction. To compare inpatient hospital stay, drainage parameters and donor-site complications associated with closed suction abdominal drain removal by post-operative day (POD) 3 regardless of output (early group), with removal after POD 3 where instructions were by drainage volume/24 h±output consistency (late group), in post-mastectomy DIEP reconstruction donor sites. A retrospective review of DIEP breast reconstructions, between January 2011 and July 2012, was undertaken to facilitate 1 year minimum follow-up per patient. Of 78 patients who underwent DIEP breast reconstructions, 74 hospital records contained complete documentation. There were 41 patients in the late, and 33 in the early removal group; both groups were matched for age and number of donor site drains (2 per patient). Mean drain removal day (4.32±0.10 days vs. 2.87±0.06 days, p<0.0001), total drainage (518.90±41.53 mls vs. 283.79±18.06 mls; p<0.0001) and hospital inpatient stay were greater for patients in the late versus early group. There were no differences in total complications (21.95% (9/41) vs. 12.12% (5/33); p=0.46), seroma (4.88% (2/41) vs. 0% (0/33); p=0.20), dehiscence (4.88% (2/41) vs. 9.09% (3/33); p=0.47) or haematoma (7.32% (3/41) vs. 3.0% (1/33); p=0.42) rates between the late and early groups. These data suggest significant advantages for patients who have abdominal drains removed early by POD 3, without increased post-operative complications including seroma rates; these data are in keeping with our LD data. We recommend drain removal and patient discharge by POD 3.