Deep Inferior Epigastric Perforator Flap Flap Research Articles

Impact on Patient’s Appearance Perception of Autologous and Implant Based Breast Reconstruction Following Mastectomy Using BREAST-Q

IntroductionThe purpose of this study is to determine if there is a better quality of life with one of the two techniques and if the results are in line with those already present in the literature. The hypothesis from which we started is to demonstrate that cancer patients who undergo a deep inferior epigastric perforator flap (DIEP) breast reconstruction surgery are more satisfied and have a higher level of quality of life compared to those subjected to an intervention of reconstruction with prosthesis.Materials and MethodsAll patients undergoing reconstruction from January 2010 to July 2018 were eligible for inclusion. This is a retrospective cohort study carried out using the patients of two plastic surgery departments who have undergone monolateral or bilateral implant-based or DIEP flap breast reconstruction. We administered BREAST-Q questionnaire electronically almost 2 year after surgery. Patients were divided into two groups: implant-based and autologous breast reconstruction with DIEP flaps. Baseline demographics and patient characteristics were analyzed using a Students t-test (continuous variables) or Chi-square/Fisher’s exact test (categorical variables). Mean standard deviation BREAST-Q scores were reported for the overall cohort and by modality for the postoperative period. The linear regression model was applied to all BREAST-Q score with all predictor factors.ResultsOf the 1125 patients involved, only 325 met the inclusion criteria and were enrolled in this study; specifically, 133 (41%) DIEP and 192 (59%) prosthetic reconstructions. We summarized the results of the principal scales of BREAST-Q module: satisfaction with breast, psychosocial well-being, satisfaction with outcome, and sexual well-being in which the autologous group was always more satisfied. We reported results of all linear regression models with higher values for the DIEP group independently from predictors.ConclusionThis is the first study performed on the Italian population that compares autologous surgical techniques with the implantation of breast implants. In this population, DIEP is considered the technique that leads to the highest satisfaction in all BREAST-Q scores.Level of Evidence IVThis 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.

The Impact of Indocyanine Green Angiography on Fat Necrosis in Deep Inferior Epigastric Perforator Flap Breast Reconstruction.

The deep inferior epigastric perforator flap (DIEP) is a widely known reliable option for autologous breast reconstruction. One common complication of DIEP procedures is fat necrosis. Consequences of fat necrosis include wound healing complications, pain, infection, and the psychological distress of possible cancerous recurrence. Clinical judgment alone is an imperfect method to detect at-risk segments of adipose tissue. Objective methods to assess perfusion may improve fat necrosis complication rates, reducing additional surgeries to exclude cancer and improve cosmesis for patients. The authors performed a retrospective review of patients who underwent analysis of DIEP flap vascularity with or without intraoperative indocyanine green angiography (ICGA). Flap perfusion was assessed using intravenous ICGA and was quantified with both relative and absolute value units of fluorescence. Tissue with observed values less than 25% to 30% relative value units was resected. Postoperative outcomes and fat necrosis incidence were collected. Three hundred fifty-five DIEP flaps were included in the study, 187 (52.7%) of which were assessed intraoperatively with ICGA. Thirty-nine patients (10.9%) experienced operable fat necrosis. No statistically significant difference in incidence of postoperative fat necrosis was found between the 2 groups (P = 0.732). However, a statistically significant relationship was found between fat necrosis incidence and body mass index as both a continuum (P = 0.001) and when categorized as greater than 35 (P = 0.038). Although ICGA is useful for a variety of plastic surgery procedures, our retrospective review did not show a reduction in operable fat necrosis when using this technology.

Abdominal Plication for Better Cosmetic Outcomes During Deep Inferior Epigastric Perforator Flap Breast Reconstruction.

Deep inferior epigastric perforator flap (DIEP) for breast reconstruction is a widely accepted technique for breast reconstruction. Secondary benefit of this technique is abdominal contour improvement. Because of direct access, abdominal plication can be performed at the time of abdominal closure. Our goal was to investigate if this addition affected the complications. A retrospective chart review was performed on all DIEP flap reconstructions performed by a single surgeon at a cancer center, from March 2011 through February 2020. Presence of abdominal plication, age, and body mass index were compared with reoperation due to abdominal wound or hernia, procedure length in minutes, and length of stay. The association between the dependent and independent variables for the unadjusted and adjusted analysis was performed using the binary logistic regression analysis. Three hundred fifty-eight DIEP flaps performed on 233 patients for breast reconstruction were analyzed. Flap loss was 1.7%. Abdominal plication was performed in 178 flaps (49.7%) and not performed in 180 flaps (50.3%). Thirty-nine percent were immediate; 61% were delayed. The results did not show a statistically significant association between abdominal plication and the need to reoperate (P = 0.3). Results from the adjusted analysis (age, body mass index) also did not show a significant association between the plication, need to reoperate, procedure duration, or hospital stay (P = 0.4). Abdominal plication can improve cosmetic outcomes without increasing the duration of surgery, hospital stay, or reoperation rates due to abdominal complications. Therefore, it can be a valuable addition in DIEP flap breast reconstructions.

Fat-Augmented Latissimus Dorsi versus Deep Inferior Epigastric Perforator Flap: Comparative Study in Delayed Autologous Breast Reconstruction.

The use of autologous tissues is considered the mainstay for delayed breast reconstruction. Aside the free abdominal flaps, which are most commonly used, the fat-augmented latissimus-dorsi (FALD) flap has been recently shown a reliable alternative option for pure autologous breast reconstruction. In this retrospective study, we aim to compare outcomes of autologous breast reconstructions using the extended FALD and deep inferior epigastric perforator flap (DIEP) flap, with an emphasis on patients' characteristics, demographic data, complications, and patients' satisfaction after a minimum 12-month follow-up. Our series consists of 135 women who underwent a delayed postmastectomy unilateral autologous breast reconstruction from 2011 to 2017: 36 patients (Group A) had an extended FALD flap and 99 (Group B) a free DIEP flap performed by the same surgeons. Demographic data, breast volume, medical history, smoking, complications, and patients' satisfaction were recorded and analyzed. Student's t-test for independent variables, Mann-Whitney U-test, and Chi-squared test were used to compare the reported variables. Patients' age, body mass index (BMI), and pregnancy history were statistically different between groups (p < 0.001, p = 0.004, p < 0.001, respectively); younger age (35.1 vs. 41.2 years), lower BMI (25.6 vs. 28.4), and fewer pregnancies were recorded in Group A. Breast volume was also found significantly smaller in Group A patients (p = 0.009). Past medical history using the ASA physical status classification score, previous radiation therapy, history of smoking, and incidence of overall complications were similar in both groups. Overall satisfaction scores were found slightly higher, but not statistically significant, in the free-flap group (p = 0.442). The use of the FALD flap may provide comparable outcome to the DIEP flap in delayed breast reconstruction in terms of complications and patients' satisfaction; it should be considered a good reconstructive option for young and thin nulliparous patients, with small to medium size opposite breast.

A systematic review of donor site aesthetic and complications after deep inferior epigastric perforator flap breast reconstruction.

The deep inferior epigastric perforator flap (DIEP) has gained widespread popularity in autologous breast reconstruction due to its natural aesthetic results and muscle-sparing design. However, donor site results regarding aesthetic outcome are often less favorable. Despite several studies on surgical technique and improvements of flap harvest, only a small number of studies addressing donor site aesthetic exist. A systematic review was performed on donor site aesthetic after DIEP flap harvest according to the PRISMA guidelines. Secondary interests were abdominal wall morbidity and complication rates in general. The following electronic databases were included to identify relevant studies: Medline, Embase, PubMed, Cochrane, and Web of Science. The search yielded 95 articles for full-text analysis, with only four key studies found on donor site aesthetic specifically. Regarding complication rates, the overall rate of abdominal hernia ranges from 0 to 7.1%. Abdominal bulging occurs in 2.3% to 33%. Besides abdominal wall integrity, wound dehiscence (12-39%), seroma (1-48%), hematoma (1-15%), infections (1-12%), fat necrosis (0-11%) and umbilical necrosis (2-3%) significantly impair donor site aesthetic. This systematic review reveals that the topic of donor site aesthetic and potential improvement of results has largely been neglected in the past decade. This study provides a thorough evaluation of potential problems that plastic surgeons may encounter and includes recommendations to improve results.

Quality of life, patient satisfaction and cosmetic outcome after delayed breast reconstruction using DIEP flap: a 10 years’ follow-up survey

Autologous breast reconstruction (BR) aims to restore body image and improve health-related quality of life in women undergoing mastectomy due to breast cancer. We wanted to explore patient-reported cosmetic results and satisfaction 10 or more years post BR surgery, using deep inferior epigastric perforator flap (DIEP). This is a follow-up study based on the same patient population of 34 patients undergoing delayed DIEP-flap procedure during 2001–2004 at Oslo University Hospital investigated by our group and published in 2008; Four patients died during the 10 years’ follow-up time and four patients with total or partial flap failure were excluded. The average age for reconstruction was 51.4 years (SD 5.8). The participants answered study-specific questions based on the first study, evaluated cosmetic results using the visual analog scale (VAS) and BREAST-Q post-mastectomy reconstruction module. The response rate was 85% (22/26). A significantly reduced number of patients reported satisfaction with the appearance of breasts (p = .035). The consistency of the reconstructed breast was significantly better evaluated with VAS score (p = .039). The patients reported overall satisfactory results based on Q-scores using the BREAST-Q post-mastectomy reconstruction module. Patients reported a generally high level of satisfaction with BR and cosmetic results 10 or more years after delayed DIEP-flap procedure. Although a significantly decreased number of patients reported satisfaction with the appearance of the breast, almost all patients would have chosen BR again, and the consistency of the reconstructed breast was evaluated as improved.

Venous thromboembolism events after breast reconstructions with DIEP free flaps in 192 consecutive case

Patient candidates for breast reconstruction with free deep inferior epigastric perforator flap (DIEP) may present several risk factors for venous thromboembolism (VTE). Risk identification is essential for appropriate VTE prophylaxis measures to be put in place. This study aims to investigate VTE incidence after DIEP flap breast reconstruction and to assess the accuracy of the Caprini Risk Assessment Model (RAM), which is the unique score validated to assess the VTE risk for plastic surgery procedures and identify patients at high VTE risk. A chart review was conducted of 192 consecutive patients who underwent breast reconstruction with a DIEP flap from 1999 to 2016. VTE rate was assessed and the Caprini score was calculated for each patient and correlated with the VTE incidence. During the 90 post-operative days, four patients presented a pulmonary embolism (2.1%) and two patients (1%) had deep venous thrombosis (overall VTE incidence of 3.1%). Most patients (92.2%) were assessed as high-risk (Caprini score >5) and all VTE occurred among this group. Apart from the Caprini score, no specific single risk factor could be identified for VTE. Our data confirm that the Caprini RAM is a valuable assessment tool for VTE risk measurement among all patients undergoing autologous breast reconstruction. As most candidates for DIEP flap belong to the high-risk group, combined anticoagulation prophylaxis methods are required for most cases, particularly chemoprophylaxis up to four weeks postoperatively.

The impact of autologous breast reconstruction using DIEP flap on the oncologic efficacy of radiation therapy

In the management of breast cancer radiation therapy plays a substantive role in decreasing local recurrence and increasing overall survival. Still, there exists controversy concerning compromised radiation delivery plans and suboptimal delivery after immediate autologous breast reconstruction. Our study aims to assess the oncologic safety of immediate breast reconstruction (IBR) with a Deep inferior epigastric perforator flap (DIEP), in the setting of adjuvant radiation therapy. We conducted a retrospective analysis using a prospectively maintained database of all consecutive women undergoing breast reconstruction with a DIEP flap in the setting of radiation therapy. Independent variables included patient age, cancer stage, tumor grade type and subtype, adjuvant and neoadjuvant chemotherapy, hormonal therapy, diabetes mellitus, and tobacco use. Main outcome variables were: local recurrence, distant metastasis, patient demise and total flap failure. From July 2008 to January 2014, and out of 450 patients who underwent reconstruction with a DIEP flap, 62 were considered eligible. Thirty patients (48%) had IBR followed by radiation therapy and 32 (52%) had delayed reconstruction preceded by radiation therapy. The two groups were comparable with respect to the independent variables. Local recurrence occurred in 3.2% of patients; 3.3% in the immediate group and 3.1% in the delayed (P=0.963). Distant metastasis occurred in 6.4% of patients: 10% in the immediate group and 3.1% in the delayed (P=0.27). Breast cancer related mortality occurred in 4.8%: 6.7% in the immediate group and 3.1% in the delayed (P=0.52). Immediate reconstruction with a DIEP flap in the setting of adjuvant radiation therapy is an acceptable approach and appears not to influence the oncologic efficacy of radiation treatment. Further prospective studies are advocated.

Smoking increases donor site complications in breast reconstruction with DIEP flap

Objective: Reconstruction with deep inferior epigastric perforator flap (DIEP) is considered to be the first choice for autologous breast reconstruction. The primary aims of this retrospective study were to find out if differences in smoking habits and BMI are useful predictors for postoperative complications in DIEP surgery.Methods: Three hundred and one patients were included. Data regarding smoking habits, BMI, age at surgery, total and final flap weight, abdominal scars, parity, number of perforators, chemotherapy, post mastectomy radiation therapy, and preoperative mapping of perforators with either Computer Tomography Angiography or hand-held ultra sound Doppler were collected. Complications that occurred in the first 30 postoperative days were taken into account.Results and conclusions: It was found that former smokers had a risk for donor site complication more than double that of never smokers (OR =2.12, CI =1.10–4.10, p = 0.025). Differences in BMI within the range from 18–33.7 did not have any significant impact on complication rates, neither at the donor site nor at the breast.

Does Postmastectomy Radiation Therapy (PMRT) After Deep Inferior Epigastric Perforator Flap (DIEP) Reconstruction Increase Complications?

The DIEP flap has become the gold standard for autologous breast reconstruction because it retains a better quality of the abdominal donor site, and there is decreased morbidity with DIEP flap compared to TRAM flap reconstruction. However, there is a paucity of literature regarding the effect of PMRT on DIEP flaps. We reviewed our experience with bilateral reconstructions receiving unilateral PMRT to evaluate the impact of RT. The objectives of the study were to assess the type and frequency of complications observed and effect on symmetry and cosmesis.

Augmentation of Venous Drainage in Deep Inferior Epigastric Perforator Flap Breast Reconstruction: Efficacy and Advancement

Deep inferior epigastric perforator flap (DIEP) is the workhorse for autologous breast reconstruction because it is associated with less abdominal wall donor site morbidity; however, the high incidence of venous congestion of zone IV within the DIEP flap is the most important disadvantage. Venous augmentation may be an appropriate method for venous decompression of the DIEP flap. This study aims to assess retrospectively the efficacy of the venous augmented DIEP flap and to present an advanced technique for venous augmentation. A total of 79 breast reconstructions using DIEP flap from January 2006 to March 2011 were included. Thirty-two patients who underwent venous augmented DIEP flap were selected as the test group, and 47 patients who underwent the traditional DIEP flap were included as the control group. Three indices-operation time, flap size, and flap complication rate-were compared between the two groups. The operation time was 6.6 ± 0.7 hours in the test group and 6.1 ± 1.2 hours in the control group (p < 0.05). The mean flap size was 325.9 ± 20.6 cm2 in the test group and 294.7 ± 24.2 cm2 in the control group (p <0.05). In the test group, there was one partial flap loss (complication rate was 3.1%). In the control group, the total complication rate was 10.6% (p <0.05). Venous augmentation can successfully enhance the viability of a DIEP flap. The SIEV-SIEV (superficial inferior epigastric vein) reverse-flow anastomosis is an efficient and convenient method of venous augmentation for DIEP flap, with negligible drawbacks.

Fibrin sealant decreases postoperative drainage in immediate breast reconstruction by deep inferior epigastric perforator flap after mastectomy with axillary dissection

Serosanguinous drainage after breast reconstruction by deep inferior epigastric perforator flap (DIEP) can limit patient's discharge. We introduced fibrin sealant in immediate breast reconstruction by DIEP flap to reduce drainage after mastectomy with axillary dissection. We performed an open study on 30 consecutive female aged from 28 to 63 years old. All underwent immediate breast reconstructions by DIEP flaps after mastectomy and axillary dissection for cancer. Patients were divided in group 1 (N = 15) without fibrin sealant and group 2 (N = 15) where the flap, thoracic, and axillary areas were sprayed with 5 mL of liquid fibrin sealant before drains insertion. There was no difference in the patient's BMI, height, weight or age between both the groups. Blake suction drains were placed under the flap and in the axillary area. No adverse effects were reported, after a 20-month median follow-up. Drainage volumes or durations were not correlated to the patient's BMI, nor the height, weight or age. Thoracic drainage duration was longer than abdominal drainage in both the groups. Average drained volumes from the thoracic area were lower (427 vs. 552 mL; P = 0.015) and thoracic drains were removed earlier (5.47 vs. 6.33 days P = 0.022), in group 2 than in group 1. The length of stay was also reduced after the use of fibrin sealant (5.53 vs. 6.33 days; P = 0.032). This study introduce the interest of fibrin sealant to significantly decrease the postoperative drainage volume and duration in the thoracic area after immediate breast reconstruction by DIEP flap.

Reconstruction mammaire par lambeau libre DIEP : à propos de 30 cas

The purpose of this study was to analyse the surgical procedure and the complications in case of breast reconstruction by deep inferior epigastric perforator flap (DIEP). This retrospective study concerns 30 cases performed between 2001 and 2005. The reconstruction was delayed (73%), immediate (3%) or realised after failed attempt to reconstruct the breast with implant or flap (27%). We studied perforator selection, operative time, total flap loss, partial flap loss, and postoperative complications. Flap was raised with one pedicle in 22 cases and with two pedicles in eight cases. The recipient vessels were the axillary vessels (70%), circumflex scapular vessels (27%), and the thoracodorsal vessels (1%). Mean operating time was 6h 17min for the one-pedicle flaps and 8h 43min for the double-pedicle flaps. We noted two total flap necrosis, four partial flap necrosis, one deep venous thrombosis and one pulmonary embolism. Postoperative abdominal hernia or bulge never occurred. Although the use of DIEP flap reduces morbidity of the harvest, long operative time and thrombosis complications cause significant morbidity. Therefore we only use the DIEP flap when other procedures cannot be performed.

Salvage of Congested Deep Inferior Epigastric Perforator Flap With a Reverse Flow Venous Anastomosis

The deep inferior epigastric perforator flap (DIEP) is an increasingly popular method for autologous breast reconstruction because of less abdominal wall donor-site morbidity. However, disadvantages with the DIEP flap are its greater technical difficulties for flap harvest and a greater incidence of venous congestion. We report a case of salvage of a congested DIEP flap with a superficial inferior epigastric vein (SIEV) to deep inferior epigastric vein reverse flow anastomosis. Drainage of both the superficial and deep system resulted in complete reversal of venous congestion and flap salvage. Preservation and use of the SIEV for venous augmentation via a reverse flow anastomosis is a novel and simple method for DIEP flap salvage of venous congestion.

Laparoscopic Mesh Repair of Transverse Rectus Abdominus Muscle and Deep Inferior Epigastric Flap Harvest Site Hernias

The transverse rectus abdominus muscle (TRAM) flap is one of the treatment options for breast reconstruction. TRAM flap reconstruction donor site herniation rates range from 1% to 8.8%. Traditionally, these hernias were treated by an open primary repair with or without the addition of onlay mesh. We report laparoscopic approach to treat TRAM and deep inferior epigastric perforator flap (DIEP) harvest site hernias with mesh. We treated 5 patients, 4 from TRAM and 1 from DIEP flap harvest site hernias during the period of October 2003 to January 2006. Two of these patients underwent previous open mesh repair with recurrence. All of these patients underwent laparoscopic hernia repair using polytetrafluoroethylene dual mesh. Follow-up ranged 6 to 31 months without any recurrences. Laparoscopic mesh repair of ventral hernias located at TRAM and DIEP flap harvest sites can be performed safely and with a low rate of recurrence.

The Use of a Deep Inferior Epigastric Perforator Flap (DIEP) in a Case of Severe Breast Asymmetry Secondary to Radiation Therapy during Childhood

Breast radiotherapy during childhood may cause unpredictable outcomes in soft tissue growth and may be responsible for most iatrogenic-related breast hypoplasias. Poor local skin quality and subcutaneous atrophy poses a difficult problem for the use of alloplastic tissues. Clinical use of a deep inferior epigastric perforator flap (DIEP) in oncological breast surgery is a common practice; however few studies have described its application in benign situations and no previous report addressed this subject. The authors indicate the use of the DIEP flap to correct severe hypomastia after previous childhood radiotherapy for hemangioma treatment, followed by unsuccessful alloplastic tissue reconstruction. For selected patients the DIEP flap may constitute a new alternative for complications of radiotherapy treatment due to the possibility of large tissue transfer with minimal donor area morbidity. The quantity of flap tissue necessary to restore the breast mound, the perforator vessel size, and the quality of suitable recipient vessels should be carefully evaluated. However, the need for microsurgical training as well as the extended surgical time are the main limiting factors for the use of this flap.

The Free Deep Inferior Epigastric Perforator Flap for the Repair of Orbita and Skull Base Defects after Tumor Resection

For the reconstruction of extended orbital and skull base defects after tumor resection, the microvascular anastomosed latissimus dorsi flap is regularly used. The free revascularized deep inferior epigastric perforator flap (DIEP) was used as an alternative in a series of consecutive cases after ablative tumor surgery. In 8 patients, full thickness soft tissue resections in the calvarial, anterior skull base, orbital, and nasal area were bridged by the flap replacing the resected volume. Seven of the 8 flaps healed uneventfully. In one case, an arterial ischemia of the flap was encountered after thrombosis of the recipient arteria. The defect repair resulted in an esthethically satisfying reconstruction of the facial contour. The primary layered closure of the abdominal wall was achieved in all cases and no complications at the donor site were observed. In our experience, the DIEP flap may serve as an alternative to the latissimus dorsi flap for these types of reconstructions. It offers the possibility for flap elevation simultaneously with the surgical procedures in the orbital and skull base area, with very little donor site morbidity.