Deep Inferior Epigastric Perforator Flap Breast Reconstruction Research Articles

Effect of Radiation Therapy on Microsurgical Deep Inferior Epigastric Perforator Flap Breast Reconstructions: A Matched Cohort Analysis of 4577 Cases.

Breast reconstruction with autologous tissue is a state-of-the art procedure. Several patient-related factors have been identified with regard to the safety and efficacy of these reconstructions. The presented study investigates the impact of prereconstruction radiation on outcomes of deep inferior epigastric perforator (DIEP) free-flap breast reconstructions using largest database available in Europe. Between 2011 and 2019, 3926 female patients underwent 4577 DIEP flap breast reconstructions in 22 different German breast cancer centers. The cases were divided into a no-radiation (NR) and a radiation (R) group, according to radiation status before reconstruction. Groups were compared with regard to surgical complications and free-flap outcome. Overall, there was no significant difference between the groups regarding the rate of total flap loss [1.9% (NR) vs 2.1% (R), P = 0.743], partial flap loss [0.9% (NR) vs 1.5 (R), P = 0.069], and revision surgery [vascular revision: 4.4% (NR) vs 4.1% (R), P = 0.686; wound revision: 7.6% (NR) vs 9.4% (R), P = 0.122]. However, the patients had a significantly higher risk of developing wound healing disturbances at the recipient site [1.2% (NR) vs 2.1% (R), P = 0.035] and showed significantly longer hospitalization {8 [SD, 8.4 (NR)] vs 9 [SD, 15.4 {R}] days, P = 0.006} after prereconstruction radiation. Our findings suggest that DIEP flap reconstruction after radiation therapy is feasible. Women with a history of radiation therapy should, however, be informed in detail about the higher risk for wound healing disturbances at the recipient site.

Preoperative computed tomography assessment for a deep inferior epigastric perforator (DIEP) flap: a new easy technique from the Bologna experience.

Deep inferior epigastric perforator (DIEP) flap reconstruction is the gold standard reconstructive technique for women undergoing breast cancer surgery. A preoperative computed tomography angiography (CTA)-dedicated protocol and 3D reconstructions are mandatory for correct surgical planning. To evaluate the diagnostic performance of a new preoperative CTA protocol and a new reconstruction method in the assessment of DIEP technique. A total of 263 women (median age 49 years, age range 26-73 years) underwent preoperative CTA examination before DIEP flap breast reconstruction. A CTA-dedicated protocol followed by 3D-reconstructions were performed. Identification, branching pattern, and caliber at origin were assessed for each perforator. Intraoperative findings were the standard of reference. The sensitivity, positive predictive value, and diagnostic accuracy of the preoperative CTA protocol were calculated. In 255/263 (97%) patients, the dominant perforators assessed by CTA resulted adequate for surgical reconstruction. In 260/263 (99%) cases, the imaging localization of the dominant perforators corresponded with those seen intraoperatively (mean errors ≤1 cm). The preoperative CTA imaging sensitivity, positive predictive value, and diagnostic accuracy in determining the localization of perforators were 99% (95% CI 98-100), 100% and 99% (95% CI 98-100), respectively. No statistically significant differences were found between the CTA findings and the surgical findings for the assessment of branching pattern and caliber of the dominant perforators (P < 0.001). The present protocol has demonstrated high accuracy in the CTA imaging assessment of the perforators before DIEP flap reconstruction with high reproducibility between CT and surgical findings.

Economic Analysis of Noninvasive Tissue Oximetry for Postoperative Monitoring of Deep Inferior Epigastric Perforator Flap Breast Reconstruction: A Review.

Background. Postoperative monitoring of deep inferior epigastric perforator (DIEP) flaps for breast reconstruction using noninvasive tissue oximetry enables timely recognition of vascular compromise. This may limit ischemic tissue damage, minimizing postoperative morbidity and healthcare costs. The aim of this review was to provide an economic analysis of tissue oximetry for postoperative monitoring of DIEP flap breast reconstruction. Methods. A systematic literature search was conducted utilizing PubMed and Embase. Articles reporting costs related to tissue oximetry following DIEP flap breast reconstruction, costs directly related to DIEP flap surgical procedure, and costs associated with postoperative complications were included. Risk of bias was assessed using different tools depending on study type. Results. Six articles were included. Four studies provided an overview of total costs associated with DIEP flap breast reconstruction; two studies focused on whether tissue oximetry could facilitate a decrease in hospital costs. Average overall costs for DIEP flap procedure were estimated at $28 000, with additional costs up to $37 530 in case of total flap failure. Tissue oximetry to monitor DIEP flaps could potentially save up to $1667 per procedure. Moreover, it might eliminate the need for specialized postoperative care. Conclusion. Tissue oximetry following DIEP flap breast reconstruction can potentially facilitate a decrease in hospital costs since its readings enable physicians to intervene in an early stage of tissue malperfusion, contributing to minimizing complications. Tissue oximetry may eliminate the need for specialized postoperative care. However, based on the current literature, no firm conclusions can yet be drawn regarding cost-effectiveness of standard implementation.

Fat Necrosis After DIEP Flap Breast Reconstruction: A Review of Perfusion-Related Causes.

Fat necrosis is a common complication for the deep inferior epigastric perforator (DIEP) flap. A thorough understanding of the factors associated with fat necrosis will aid operative planning for reconstructive surgeons. A systematic review of the literature was performed between January 1989 and April 2019. Studies were included if they reported on fat necrosis in DIEP flap or evaluated the perfusion of the DIEP flap. Twenty-eight out of 312 studies met the inclusion and exclusion criteria. Fat necrosis rates ranged from 12.0 to 45.0% on clinical examination within the literature. The four main perforator-specific factors identified included perforator perfusion zones, perforator location, perforator number and venous congestion. Medial row perforators have a wider perfusion zone, while lateral row perforators have a narrow perfusion zone. Holm zone III has a higher rate of fat necrosis compared to Holm zone II. One to two perforators and more than five perforators and a Type III atypical connection between the superficial and deep venous system had a higher rate of fat necrosis. The DIEP flap should incorporate between two and three perforators of a substantial calibre; Holm zone III should be excluded if able and careful review of the pre-operative imaging should be performed to analyse the connections between the deep and superficial venous system. There are multiple perfusion-related factors to consider when planning the DIEP flap and ultimately a patient-specific approach to the vascular anatomy is essential. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Optimizing Quality of Life for Patients with Breast Cancer-Related Lymphedema: A Prospective Study Combining DIEP Flap Breast Reconstruction and Lymphedema Surgery.

Patients with breast cancer-related lymphedema can be treated with a simultaneous deep inferior epigastric perforator (DIEP) flap, vascularized inguinal lymph node transfer, and lymphovenous anastomosis for aesthetic breast reconstruction and lymphedema in one operation. The authors performed a comparison of prospectively followed patients who underwent free flap breast reconstruction with vascularized inguinal lymph node transfer and anastomosis to a retrospective cohort of patients who underwent free flap breast reconstruction with vascularized inguinal lymph node transfer alone. Thirty-three patients underwent DIEP flap reconstruction with vascularized inguinal lymph node transfer and lymphovenous anastomosis, and 21 received a free flap with lymph node transfer alone. There were no significant differences in demographics, adjuvant chemotherapy, or radiation therapy. The average number of nodes removed was also equivalent (21.2 versus 21.4 nodes). Two anastomoses per patient, on average, were performed (range, one to four) in the combined cohort, and all patients (100 percent) reported a subjective improvement in symptoms, compared with 81.0 percent of patients undergoing only lymph node transfer (p = 0.019). Perometer measurements demonstrated a significant reduction between the groups at early time points [3 months, 40.7 percent versus 20.0 percent (p = 0.037); 6 months, 57.0 percent versus 44.5 percent (p = 0.043)]; however, the difference was not statistically significant at 12 months (60.4 percent versus 57.8 percent; p = 0.43). This is the first prospective study demonstrating the safety and efficacy of a combined DIEP flap with vascularized inguinal lymph node transfer and lymphovenous anastomosis, which may be superior to lymph node transfer alone. Therapeutic, III.

Clinical Impact of DIEP Flap Perforator Characteristics – A Prospective Indocyanine Green Fluorescence Imaging Study

The question to what extent perfusion in deep inferior epigastric perforator (DIEP) flaps depends on specific perforator characteristics has been raised. Anatomical studies and previous clinical trials focussing on DIEP flap perfusion resulted in discrepancies. This prospective study investigates how perforator row, number and diameter affect DIEP flap microperfusion via Indocyanine Green (ICG) fluorescence angiography. The fractional weight of insufficiently perfused flap tissue in Zone 4 related to the total DIEP flap weight was measured based on ICG fluorescence angiography and defined as Zone 4 %. As a surrogate for overall DIEP flap perfusion, Zone 4 % was assessed according to the row, number and diameter of perforators included in the flap. In 42 unilateral DIEP flap breast reconstructions, neither medial (33.6 ± 14.2 %)/lateral perforator row (29.9 ± 7.5 %, p = 0.683) nor the parameter perforator number (single perforator 31.5 ± 14.4 %, two perforators 30.2 ± 10.2 %, p = 0.727) had a statistically significant effect on flap tissue availability as measured via Zone 4 %. A negative correlative trend between perforator diameter and Zone 4 % (r = -0.096, p = 0.588) was observed. Zone 4 % provides a novel method for an objective assessment of DIEP flap perfusion. Medial/lateral row selection and other perforator properties (number, diameter) within the standard ranges, did not affect Zone 4 % as indicated by ICG fluorescence angiography.

Refractory Donor-Site Seroma Following DIEP Breast Reconstruction

Donor-site seroma formation is a complication of autologous breast reconstruction reported most commonly with the use of latissimus dorsi flaps. First-line treatment is percutaneous aspiration which leads to resolution in the majority of cases. Those that persist may progress to a chronic, refractory seroma, which can prove challenging in terms of treatment. The aim of this article is to provide an updated literature review of interventions for chronic donor-site seroma and present the case of a 65-year-old female with a recalcitrant abdominal seroma following deep inferior epigastric perforator (DIEP) flap breast reconstruction. Literature review revealed a single article that reported 2 cases of persistent donor-site seroma after DIEP flap breast reconstruction. The patient presented here underwent repeat aspiration, drain placement, and multiple surgical procedures to achieve resolution. In total, the post-reconstruction seroma history of the patient extended over approximately 14 months. We conclude with evidence-based suggestions for chronic, donor-site seroma prevention and treatment.

Breast reconstruction using Deep Inferior Epigastric Perforator (DIEP) flap in a patient with heterozygous Factor V Leiden: a case report

Factor V Leiden (FVLeiden) mutation is the commonest type of inherited thrombophilia. Free tissue transfer is very rarely used in such patients due to concerns about microvascular thrombosis and flap failure. Even when rarely offered, the peri-operative antithrombotic regimen for such cases is widely varied and based of personal experiences and preference. These regimens usually include multiple pharmacologic agents but their real benefit is based merely on anecdotal evidence. On the other hand, the potential complications of such drugs are well established in literature. Deep Inferior Epigastric Perforator (DIEP) flap is the most widely used autologous breast reconstruction technique. Here, we report a case of successful free DIEP flap breast reconstruction in a lady with heterozygous FVLeiden mutation. We have described our approach to this patient, including the simple single drug anticoagulation regimen used as advised by the hematologists for venous thromboembolism (VTE) prophylaxis. We have compared our approach to that of others who have reported similar cases before. Our report shows that it is feasible to offer successful free tissue breast reconstruction to these patients by following meticulous surgical technique without the need of additional systemic antithrombotic agents over and above the simple regimen indicated for general VTE prophylaxis.

Immediate Breast Reconstruction with a Deep Inferior Epigastric Perforator Flap in the Lithotomy Position.

Mastectomy and flap harvesting can be accomplished simultaneously in immediate deep inferior epigastric perforator (DIEP) flap breast reconstruction. However, this is not always possible, particularly in a teaching institution, where supervisors, trainees, and assistants must participate in the surgery, because there is not enough working space for breast and plastic surgeons to perform surgery together. We attempted to overcome this problem by placing the patient in the lithotomy position and have reported the outcomes. We evaluated patients who underwent unilateral immediate DIEP flap breast reconstruction in the supine or lithotomy position between October 2014 and July 2016. The surgeries were performed by the same inexperienced plastic surgeon in our hospital. In the lithotomy position, 1 plastic surgeon stands between the patient's legs and 1 stands beside the abdomen, and they perform DIEP flap harvesting simultaneously with mastectomy performed by 3 breast surgeons. After mastectomy, breast reconstruction is performed by 4 plastic surgeons. The supine position was used in the first 8 patients, and the lithotomy position was used in the following 8 patients. The mean operative time was 11 hours 21 minutes in the supine group and 8 hours 52 minutes in the lithotomy group, with a significant difference (P = 0.027). Breast reconstruction with a DIEP flap in the lithotomy position is useful for teaching institutions because it provides sufficient working space and allows simultaneous procedures without prolonging operative time. However, issues such as pressure sores, nerve palsy, and difficulty in patient placement still exist.

Increase of major complications with a longer ischemia time in breast reconstruction with a free deep inferior epigastric perforator (DIEP) flap

BackgroundThe deep inferior epigastric artery perforator (DIEP) flap is one of the most used free flaps for postmastectomy breast reconstruction. Prolonged ischemia can result in (partial) flap loss. The aim of this study was to evaluate the association between ischemia time and postoperative complications of DIEP flap breast reconstruction. MethodsA retrospective study of all patients who received a breast reconstructionwith aDIEP flap atMaastricht University Medical Center in theNetherlands, between January 2010 and June 2017 (n = 677). The flaps were divided into two groups: flaps with an ischemia time less than 60 min and those with 60 min or more. Recipient site complications, in particular major complications equal to re-exploration, and partial or total flap loss were the primary outcome measures.ResultsIn 23.9% of the 677 included DIEP flaps, the ischemia time was 60 min or longer. Within this group, a complication of the recipient site occurred in 30.9% of the flaps. A major complication occurred in 17.3% of the flaps with 60 min or more ischemia time.With regard to the flaps with less than 60-min ischemia time, a complication occurred in 22.1% of the cases of which 8.9%would be considered amajor complication. A significant association was found between ischemia time and major complications on univariate (p value = 0.003) and multivariate analyses (p value = 0.016).ConclusionsThis study demonstrates that an ischemia time less than 60 min is associated with a significantly lower risk of major recipient site complications compared to an ischemia time of 60 min or more.Level of evidence: Level III, therapeutic, risk/prognostic study.

Impact of Rectus Muscle Injury during Perforator Dissection on Functional Donor Morbidity after Deep Inferior Epigastric Perforator Flap Breast Reconstruction.

Background:This study aimed to assess the extent of rectus muscle damage in deep inferior epigastric perforator (DIEP) flap harvest and to evaluate its association with functional donor morbidity.Methods:A prospective cohort of 76 patients who underwent DIEP flap breast reconstruction was evaluated preoperatively and followed up for 1 year. Abdominal wall strength was assessed using the upper and lower rectus abdominis manual muscle function tests. Functional weakness was defined as a postoperative decrease in function by at least 2 scores. The effects of patient- and operation-related characteristics on adverse outcomes were also assessed.Results:The mean width of the transected rectus muscle was 2.2 cm (partial thickness, 1.8 cm; full thickness, 0.4 cm). The mean width ratio of the overall injured muscle to the entire bilateral muscle was 0.18. Muscle injury was more severe in the cases with bipedicled flap elevation and in those with 4 or more perforators harvested. Functional weakness was detected in 13 patients (17.1%). Multivariate analyses demonstrated that the width ratio of the muscle injury was an independent predictor of functional weakness. The width ratio achieved maximal discrimination regarding the rate of functional weakness at a threshold value of 0.12, indicating that functional weakness did not develop in all 19 cases with a width ratio of <0.12.Conclusions:The extent of rectus muscle injury during perforator dissection may be associated with functional donor morbidity after DIEP flap harvest. This may be beneficial in achieving proper balance between securing flap perfusion and preserving donor functions.

Rezoning Free Muscle-Sparing Transverse Rectus Abdominis Myocutaneous Flaps Based on Perforasome Groupings and a New Understanding of the Vascular Architecture of the Deep Inferior Epigastric Artery-Based Flaps.

We compare the vascular territory of free muscle-sparing transverse rectus abdominis myocutaneous (MS-TRAM) flaps, deep inferior epigastric perforator (DIEP) flaps, and crossover anastomosis (CA) flaps using intraoperative ex vivo angiography. We also use ex vivo angiography to analyze the vascular architecture of the MS-TRAM flap. Our study includes 84 lower abdominal free flaps: MS-TRAM, DIEP-1 (1 perforator), DIEP-2 (2 perforators), and CA. We compare the arterial perfusion area and vascular territory pattern in each group. We also analyze the vascular architecture in MS-TRAM flaps and determine the number and location of their dominant perforators and the direction of the axial arteries connecting them. The CA's arterial perfusion area is the largest, and the DIEP-1's, the smallest of our groups; there is no statistically significant difference between MS-TRAM and DIEP-2. In all groups, average arterial perfusion area in the vascular pedicle's ipsilateral side is larger than in its contralateral side. The MS-TRAM and DIEP-2 flaps have homologous perfusion patterns and the same arterial perfusion areas. The DIEP-1 perfusion pattern varies with perforator location. Ex vivo angiograms show the MS-TRAM flap's axial arteries heading laterally to be larger and longer than those heading medially. Two dominant perforators are preferable in DIEP flap breast reconstruction. Lateral perforators play a more important role in flap perfusion than do medial ones. Crossover anastomosis is an effective technology for increasing arterial perfusion areas. Our rezoning shows which areas are better for surgery and which have a high risk of complications-valuable information for a surgeon designing a flap for breast reconstruction.

Prospective Longitudinal Patient-Reported Satisfaction and Health-Related Quality of Life following DIEP Flap Breast Reconstruction: Relationship with Body Mass Index.

Breast reconstruction plays a significant role in breast cancer treatment recovery. Introduction of the BREAST-Q questionnaire has facilitated quantifying patient-reported quality-of-life measures, promoting improved evidence-based clinical practice. Information regarding the effects of body mass index on patient-reported outcomes and health-related quality of life is significantly lacking. Consecutive deep inferior epigastric perforator (DIEP) flap breast reconstruction patients prospectively completed BREAST-Q questionnaires preoperatively and at two points postoperatively. The first (postoperative time point A) and second (postoperative time point B) postoperative questionnaires were completed 1 month postoperatively and following breast revision, respectively. Postoperative flap and donor-site complications were recorded prospectively. BREAST-Q scores were compared at all time points and stratified by body mass index group (≤25, >25 to 29.9, 30 to 34.9, and ≥35 kg/m). Between July of 2012 and August of 2016, 73 patients underwent 130 DIEP flap breast reconstructions. Breast satisfaction and psychosocial and sexual well-being scores increased significantly postoperatively. Chest and abdominal physical well-being scores returned to baseline levels by postoperative point B. Preoperatively, stratified by body mass index, breast satisfaction and psychosocial well-being scores were significantly lower among patients with body mass index of 35 or higher and of more than 30, respectively. After reconstruction, not only were breast satisfaction, psychosocial, and sexual well-being scores significantly improved in all body mass index groups versus baseline, but also between-body mass index group differences were no longer present. Outcome satisfaction, flap, and donor-site morbidity were similar irrespective of body mass index. Patient-reported outcomes demonstrate significant improvements in breast satisfaction and psychosocial and sexual well-being among patients following DIEP flap reconstruction. Preoperative differences in quality-of-life scores were improved in patients with obesity (body mass index ≥30 kg/m). Risk, II.

Use of Strict Patient Selection Criteria to Achieve Significant Surgical Outcomes from a Low DIEP Flap Breast Reconstruction.

The low deep inferior epigastric perforator (DIEP) flap was first introduced in 2016 as it had aesthetic advantages over the conventional DIEP flap. With our experience of over 100 low DIEP flap procedures to date, we have conspicuously lowered complication rates and established more definitive criteria to select proper candidates. We analyzed 103 patients who underwent breast reconstruction with the low DIEP flap at our hospital between May 2014 and June 2018. Demographics, patient selection criteria, flap specifics, surgical outcomes including postoperative complications, and the location of the abdominal scar and umbilicus were reviewed retrospectively. The mean patient age was 46.7 years, and the average body mass index was 23.7 kg/m2. A low DIEP with an average weight of 377 g was utilized within 6 hours 17 minutes in this cohort. There was no significant difference in the rate of venous congestion or fat necrosis compared with the conventional DIEP flap. The average distance from the pubic hairline to the abdominal scar was 0.6 cm and from the anterior superior iliac spine to the abdominal scar was -0.4 cm. The postoperative location of the umbilicus was 7.0 cm above the pubic hairline. The low DIEP flap is not only a reliable option for a breast reconstruction but is an aesthetically superior approach with a lower abdominal scar and natural umbilicus. Patients may benefit from this technique if prudently selected by computed tomography (CT) angiography. A perforator that is larger than 1 mm in diameter and well enhanced on CT angiography from the division of the external iliac artery to the abdominal skin particularly in the intramuscular course should be selected.

Contralateral unaffected breast augmentation using zone IV as a SIEA flap during unilateral DIEP flap breast reconstruction

BackgroundContralateral breast augmentation during unilateral breast reconstruction is a good option for women with small breasts. In patients with adequate lower abdominal tissues, the deep inferior epigastric perforator (DIEP) flap is often the first choice for unilateral autologous breast reconstruction. We use Zone IV, which is usually excised owing to its insufficient blood circulation, as a superficial inferior epigastric artery (SIEA) flap for contralateral breast augmentation. MethodsBetween October 2004 and January 2016, 32 patients underwent unilateral breast reconstruction using a DIEP flap and an attempted simultaneous contralateral breast augmentation with an SIEA flap. The unilateral DIEP flap attached to the contralateral SIEA flap was split into two separate flaps after indocyanine green angiography. In all patients, ipsilateral internal mammary vessels were used as recipient vessels for DIEP flap breast reconstruction. The SIEA flap pedicle was anastomosed to several branches of the deep inferior epigastric vessels. The SIEA flap was inset beneath the contralateral breast through the midline. ResultsOf 32 patients, 27 underwent DIEP flap breast reconstruction and simultaneous unaffected breast augmentation using 25 SIEA or 2 superficial circumflex iliac artery perforator (SCIP) flaps. All DIEP flaps survived, and total necrosis occurred in one SIEA flap. The mean weight of the final inset for DIEP flap reconstruction and SIEA or SCIP flap augmentation was 416 g and 112 g, respectively. ConclusionsUnilateral DIEP flap breast reconstruction and contralateral SIEA flap breast augmentation may be safely performed with satisfactory results.

Optimizing DIEP Flap Insetting for Immediate Unilateral Breast Reconstruction: A Prospective Cohort Study of Patient-Reported Aesthetic Outcomes.

To improve the aesthetic outcome of deep inferior epigastric perforator (DIEP) flap breast reconstruction, flaps should be tailored to the patient's characteristics. A single method of DIEP flap insetting will not suffice for all women seeking breast reconstruction. The authors share the outcomes of a prospective longitudinal study on DIEP flap insetting and present an algorithm for reconstruction. Over 4 years, 70 consecutive immediate unilateral DIEP flap breast reconstructions were prospectively evaluated. DIEP insetting was based on the characteristics of the donor site and contralateral breast, according to the authors' algorithm. Baseline and outcome data were collected. Aesthetic outcomes were evaluated by a panel of three independent assessors, and patient-reported outcomes were quantified using the BREAST-Q at 1 year after reconstruction. Seventy women underwent reconstruction. There were no total or partial flap failures, four cases of fat necrosis, and 14 revision operations. Women reported a mean overall BREAST-Q score of 82 of 100, representing excellent satisfaction but poor satisfaction with sexual well-being. BREAST-Q scores were not associated with age or body mass index. Fat necrosis reduced satisfaction with the chest (absolute mean reduction, 13; 95 percent CI, 8 to 18; p = 0.002). Independent assessors scored the outcomes favorably, but there was no agreement between surgeons, nurses, and lay assessors. The authors' algorithm can support surgeons in selecting individually tailored DIEP flap insetting to achieve excellent aesthetic outcomes. Further research is needed as to the relevance of scores from BREAST-Q in relation to interventions. Therapeutic, IV.

Epidural Nerve Blocks Increase Intraoperative Vasopressor Consumption and Delay Surgical Start Time in Deep Inferior Epigastric Perforator Free Flap Breast Reconstruction.

Background:Epidural nerve blocks (EA) have been widely used in abdominal and thoracic surgery as an adjunct to general anesthesia (GA). The role for EA in microsurgical free flap breast reconstruction remains unclear with concerns regarding its impact on flap survival and operating room efficiency. The purpose of this study was to examine the effectiveness of epidural blocks in patients undergoing deep inferior epigastric perforator (DIEP) flap breast reconstruction.Methods:A retrospective analysis of patients undergoing DIEP breast reconstruction under GA alone was compared with those receiving EA/GA. Electronic records were analyzed for patient demographics, intraoperative data, and postoperative outcomes. The primary outcome was 48-hour narcotic usage and secondary outcomes were intraoperative vasopressor consumption, surgical delay, and safety profile.Results:Sixty-one patients underwent DIEP reconstruction, 46 (75%) underwent EA/GA and 15 (25%) underwent GA alone. Epidural blocks were associated with a significant delay in operating room start time (67.8 min versus 45.6 min; P = 0.0004.) Patients in the EA/GA group also had a significant increase in vasopressor use (n = 38 versus n = 8; P = 0.037); however, there was no difference in flap complication rate [1 (2%) versus 2 (13%); P = 0.15]. Postoperatively, patients who received an epidural block had a reduced average pain score (1.1 versus 2.2; P = 0.0235), but there was no difference in 48-hour narcotic usage.Conclusions:Although epidural blocks reduce postoperative pain following DIEP flap breast reconstruction, they increase intraoperative vasopressor use and delay the start time of the case. Further studies are required to elucidate whether the benefits of improved pain control outweigh the potential risk for increased surgical complications and increased health care costs.

The Outpatient DIEP: Safety and Viability following a Modified Recovery Protocol.

Background:Breast reconstruction with autologous tissue is considered the current state-of-the-art choice following mastectomies, and the deep inferior epigastric perforator (DIEP) flap is often among the favored techniques. Commonly referred to patients as a combination between a tummy tuck and a breast augmentation, it significantly differs by the required expertise and long hospital stays. We present a series attesting to the feasibility and effectiveness of performing this type of reconstruction in an outpatient setting following our recovery protocol.Methods:Patients undergoing DIEP flap breast reconstruction followed a recovery protocol that included intraoperative local anesthesia, microfascial incision technique for DIEP harvest, double venous system drainage technique, rib and chest muscle preservation, and prophylactic anticoagulation agents.Results:Fourteen patients totaling 27 flaps underwent breast reconstruction following our protocol. All patients were discharged within the initial 23 hours, and no take-backs, partial, or total flap failures were recorded. A case of abdominal incision breakdown was seen in 1 patient during a postoperative visit, without evidence of frank infection. No further complications were observed in the 12-week average observation period.Conclusion:With the proper use of a microfascial incision, complemented by rib sparing and appropriate use of injectable anesthetics, routine breast reconstructions with the DIEP flap can be safely performed in an outpatient setting with discharge in the 23-hour window.

Survival and risk of breast cancer recurrence after breast reconstruction with deep inferior epigastric perforator flap.

Women who undergo autologous breast reconstruction have been reported to have an increased risk of breast cancer recurrence compared with those who have mastectomy alone. It has been suggested that more extensive surgery possibly activates dormant micrometastases. The aim of this study was to evaluate whether delayed unilateral deep inferior epigastric perforator (DIEP) flap reconstruction after mastectomy increases the risk of breast cancer recurrence or affects mortality among women previously treated for breast cancer. This was a matched retrospective cohort study including women with a previous unilateral invasive breast cancer who received a delayed DIEP flap breast reconstruction and a control cohort of individually matched women with unilateral breast cancer who underwent mastectomy but no autologous breast reconstruction. Matching criteria comprised: year of diagnosis (+/-3 years), age at diagnosis (+/-5 years), type of cancer and demographic region. The primary endpoints were local recurrence or distant metastasis, and overall mortality was a secondary endpoint. Absolute risk of recurrent disease and mortality was analysed, and relative risks were estimated using Cox proportional hazards analysis. There were 225 women in the DIEP cohort and 450 in the no-DIEP cohort. The median follow-up time was 125 months. There was no difference in absolute risk of recurrence between the cohorts. The hazard ratio for breast cancer recurrence in DIEP versus no-DIEP cohorts was 0·76 (95 per cent c.i. 0·47 to 1·21). There is no increased risk in breast cancer recurrence after delayed DIEP flap reconstruction compared with mastectomy alone.

Volume change in the rectus abdominis muscle after deep inferior epigastric perforator flap harvest

Deep inferior epigastric perforator (DIEP) flap is associated with less donor site morbidity than transverse rectus abdominis myocutaneous flap. However, abdominal muscle atrophy and donor site complications caused by denervation during pedicle dissection cannot be avoided. This retrospective study investigated the change in the rectus abdominis muscle volume after DIEP flap harvest. Of 395 patients who underwent unilateral DIEP flap breast reconstruction between August 2007 and July 2017, 25 patients with >2-year postoperative abdominal computed tomography data were evaluated. Preoperative and postoperative images of the abdominal muscle after pedicle dissection and the nonoperated side were compared. The volume of the muscles from the lower margin to the umbilicus was determined by using OsiriX image analysis application. The muscle volumes on the side of pedicle dissection decreased from 72.63 ± 23.29 cm3 preoperation to 53.09 ± 16.93 cm3 postoperation (p < 0.001). The corresponding volumes on the side without dissection were 73.29 ± 19.25 cm3 and 60.89 ± 18.79 cm3 (p < 0.001). The percentage of postoperative retained volume relative to the preoperative retained volume was 75.65% ± 19.18% on the pedicle dissection side and 84.65% ± 19.00% on the contralateral side. The 9% difference was not statistically significant (p = 0.10). No major abdominal complications were observed. Despite nerve injury during DIEP flap surgery, the volume loss of the involved and contralateral muscles did not differ. More than 75% of the abdominal muscle volume was retained. Muscle integrity was well maintained without any postoperative complications.