Deep Inferior Epigastric Perforator Flap Harvest Research Articles

Evolution and Adaptations of Robotic DIEP Flap Surgery: A Systematic Review.

The integration of robotic technology into surgical procedures has gained considerable attention for its promise to enhance a variety of clinical outcomes. Robotic deep inferior epigastric perforator (DIEP) flap harvest has emerged as a novel approach for autologous breast reconstruction. This systematic review aims to provide a comprehensive overview of the current techniques, outcomes, and complications of robotic DIEP flap surgery. A systematic literature search was conducted after PRISMA 2020 guidelines across databases including PubMed, Embase, Google Scholar, and Web of Science from 2000 to 2023. Articles exploring robotic DIEP flap harvest for breast reconstruction were assessed to compare operative techniques, clinical outcomes, and complications. The risk of bias was evaluated using ROBINS-I and the Newcastle-Ottawa scale. Fourteen studies involving 108 patients were included. Three studies used a totally extraperitoneal (TEP) technique, whereas 11 studies used a transabdominal preperitoneal (TAPP) approach. Preoperative planning utilized computed tomography angiography and magnetic resonance angiography imaging. The mean robotic operative time was 64 minutes, with total operative times averaging 574 minutes for TAPP and 497 minutes for TEP. The mean length of stay was 5 days, and the mean fascial incision length was 3cm. Overall complication rate was 14.9%, with no significant difference compared with conventional DIEP flap procedures. Robotic DIEP flap harvest is a promising technique that may reduce postoperative pain and limiting abdominal donor site morbidity. Potential limitations include longer operative times, variable hospital stays, and increased costs.

Embracing Robotics in Microsurgery: Robotic-Assisted Deep Inferior Epigastric Perforator Flap Breast Reconstruction.

The integration of robotic-assisted surgery (RAS) has transformed various surgical disciplines, including more recently plastic surgery. While RAS has gained acceptance in multiple specialties, its integration in plastic surgery has been gradual, challenging traditional open methods. Robotic-assisted deep inferior epigastric perforator (DIEP) flap breast reconstruction is a technique aimed at overcoming drawbacks associated with the traditional open DIEP flap approach. These limitations include a relatively large fascial incision length, potentially increasing rates of postoperative pain, abdominal bulge, hernia rates, and core weakening. The robotic-assisted DIEP flap technique emerges as an innovative and advantageous approach in fascial-sparing abdominal autologous breast reconstruction. While acknowledging certain challenges such as increased operative time, ongoing refinements are expected to further improve the overall surgical experience, optimize results, and solidify the role of robotics in advancing reconstructive microsurgical procedures in plastic surgery. Herein, the authors provide an overview of robotic surgery in the context of plastic surgery and its role in the DIEP flap harvest for breast reconstruction.

Learning Curve Analysis for Robotic-assisted Harvest of Deep Inferior Epigastric Perforator Flap

Summary: The deep inferior epigastric perforator (DIEP) flap is the preferred method for autologous breast reconstruction after mastectomy, but risks the development of hernia, bulge, and decreased core strength. Robotic harvest of DIEP vessels may limit abdominal wall morbidity through smaller fascial incisions and preservation of motor nerves. This study shows the expected learning curve (LC) for robotic harvest and compares the LC between a general surgeon (GS) and a plastic surgeon (PS). A retrospective cohort study was performed for patients who underwent bilateral robotic DIEP flap harvest from October 2021 to September 2022. We evaluated robotic pedicle dissection time (DT) and compared the times between GS and PS. We calculated LC for each surgeon using the cumulative sum (CUSUM) method, . The LC was identified as the peak of the CUSUM graph. Forty-four flap dissections were recorded during the collection period: 27 by the PS and 17 by the GS. There was no significant difference in DT between the GS and the PS (P = 0.366), and both surgeons saw a decrease in DT over time. Using the CUSUM method, we see the peak of the plot at patient 9 for the PS and the peak of the plot at patient 5 for the GS, after which cumulative DT decreased. As robotic harvest of DIEP flaps becomes accepted, plastic surgeons who wish to incorporate it into their practice may achieve proficiency in their DT within 10 flap harvests and a similar DT compared with robotic-trained GSs.

Robotic-Assisted DIEP Flap Harvest for Autologous Breast Reconstruction: Case Report, Technical Aspects and Identification of Suitable Patients

Robotic-assisted harvest of the deep inferior epigastric perforator (DIEP) flap is an innovative modification of the traditional open preparation for autologous breast reconstruction. It is assumed that donor-site morbidity (herniae, bulging) is reduced by minimising the fascial incision length in robotic-assisted DIEP flap harvest. This is the first report of a robotic-assisted DIEP harvest in Germany, which was performed in April 2023 at the University Hospital of Freiburg in an interdisciplinary approach of the Departments of Plastic Surgery, Urology and Gynaecology. To determine the value of this novel technique, we assessed the demand by retrospectively performing an analysis of potential patients and conducted a cost analysis based on the breast reconstructions with DIEP flap harvest performed between April 2021 and May 2023 at the Department of Plastic Surgery at Freiburg University Hospital. To this end, we carried out a retrospective analysis of preoperative CT angiographies to determine the proportion of patients suitable for a robotic-assisted procedure in a post-hoc analysis. Furthermore, we describe the basic robotic-assisted techniques and discuss the TEP and TAPP laparoscopic approaches. In line with the previously published literature, a short intramuscular course (≤25 mm) and a perforator diameter of≥1.5 mm and≥2.7 mm (subgroup) were defined as a crucial condition for the robotic-assisted procedure. We analysed 65 DIEP flaps harvested in 51 patients, of which 26 DIEP flaps in 22 patients met both criteria, i. e.≤25 mm intramuscular course and≥1.5 mm diameter of the perforator, while 10 DIEP flaps in 10 patients additionally met the criteria of the subgroup (≥2.7 mm diameter). Based on the intramuscular course of the perforators in the CT angiographies of those 26 DIEP flaps, a potential reduction of the fascial incision of 96.8±25.21 mm (mean±standard deviation) compared with the conventional surgical approach was calculated. The additional material costs in our case were EUR 986.01. However, ischaemia time was 33,5 minutes longer than the median of the comparative cohort. The robotic-assisted procedure has already proven to be a feasible alternative in a suitable patient population. However, further studies are needed to confirm that robotic-assisted DIEP flap harvest actually reduces harvest site morbidity and thereby justifies the additional costs and complexity.

The Donut DIEP Flap: A Novel Scarless Technique.

Deep inferior epigastric perforator (DIEP) flap surgery is a common technique for breast reconstruction. However, the long and noticeable abdominal scarring is one of its greatest disadvantages. Here, we suggest a minimal scarring DIEP flap harvest with a novel abdominal design. The key to this method is to preserve more skin tissue with a circular design centered around the navel. Three circular incisions are made: (1) the smallest circle represents an incision around the umbilicus; (2) the middle circle with a radius of <3.5 cm indicates skin incision because the donut-like skin paddle between the small and middle circles is included in the flap; (3) the largest circle with a radius of >10 cm represents the extent of flap dissection that was done diagonally from the skin toward the Scarpa's fascia. Pedicle dissection is proceeded with the conventional method. For closure, a purse-string suture is performed with the umbilicus at its center leaving only a single small circular scar around the umbilicus as the final scar. Closure of the donor-site is possible with the patient in a supine or slightly flexed position due to less skin excision. LEVEL OF EVIDENCE: Therapeutic, V.

Evaluating mesh use for abdominal donor site closure after deep inferior epigastric perforator flap breast reconstruction: A systematic review and meta-analysis.

Despite improvement in abdominal morbidity with deep inferior epigastric perforator (DIEP) flap breast reconstruction compared to prior abdominally-based free flap breast reconstruction, abdominal bulge, and hernia rates have been cited anywhere from 2% to 33%. As a result, some surgeons utilize mesh or other reinforcement upon donor-site closure, but its benefit in preventing abdominal wall morbidity has not been well-defined for DIEP flaps. The purpose of this systematic review is to evaluate DIEP donor-site closure techniques and the impact of mesh type and plane on abdominal-wall morbidity including hernia and bulge, relative to primary fascial closure. MEDLINE, PubMED, Cochrane Library, and SCOPUS were systematically reviewed for studies evaluating DIEP flap breast reconstruction abdominal-donor site closure, where any mesh reinforcement or primary fascial closure was specified, and postoperative outcomes of hernia and/or abdominal bulge were reported. Analysis was performed in Review Manager (RevMan) evaluating mesh use, type, and plane relative to primary fascial closure, using the Mantel-Haenszel method to calculate odds ratios (ORs) of significance level p < .05, and a random effects model to account for inter-study heterogeneity. Of the 2791 DIEP patients across 11 studies, 1901 patients underwent primary closure and 890 were repaired with mesh. When hernia and/or bulge were combined into a single complication, the use of any mesh did not significantly reduce its odds compared to primary closure (OR = 0.69, p = .20). Similarly, the use of any mesh did not significantly reduce the odds of bulge alone compared to primary closure (OR = 0.62, p = .43). However, the odds of hernia alone were significantly reduced by 72% with any mesh use (OR = 0.28, p = .03). Mesh use was significantly associated with decreased odds of hernia alone with DIEP flap surgery, but there was no difference in bulge or combined hernia/bulge rates. As bulge is the more common abdominal morbidity after DIEP flap harvest in a patient with no prior abdominal surgery or risk factor for hernia, mesh use is not indicated in abdominal closure of all DIEP patients. Future prospective studies are warranted to characterize the specific indications for mesh use in the setting of DIEP flap surgery.

Preoperative Imaging Mapping of DIEP Perforators and Intraoperative Selection: Does It Correlate?

Preoperative imaging prior to deep inferior epigastric perforator (DIEP) flap harvest is a common practice to locate perforators and identify aberrant anatomy. We report a retrospective review of 320 consecutive patients who underwent preoperative computed tomographic angiography (CTA) or magnetic resonance angiography prior to DIEP flap breast reconstruction. The locations relative to the umbilicus of preoperatively identified perforators were compared with the selected intraoperative perforators. The diameter of all intraoperative perforators was also measured. Across the 320 patient, 1,833 potentially suitable perforators were identified on preoperative imaging. A total of 564 of the 795 perforators selected intraoperatively for DIEP flap harvest were within 2 cm of a predicted perforator, for a rate of 70.1%. The size of the perforator was unrelated to the detection rate. We were able to demonstrate a sensitivity of 70% of clinically selected DIEP perforators identified on preoperative imaging in this large series. This contrasts with the nearly 100% predictive value reported by others. Continued reporting of findings and methods of measuring are needed to improve the practical efficacy of CTA and raise awareness about the limitations of CTA, despite its well-documented usefulness.

A Machine Learning Approach to Predicting Donor Site Complications Following DIEP Flap Harvest.

The additional donor site incisions in autologous breast reconstruction can predispose to abdominal complications. The purpose of this study is to delineate predictors of donor site morbidity following deep inferior epigastric perforator (DIEP) flap harvest and use those predictors to develop a machine learning model that can identify high-risk patients. This is a retrospective study of women who underwent DIEP flap reconstruction from 2011 to 2020. Donor site complications included abdominal wound dehiscence, necrosis, infection, seroma, hematoma, and hernia within 90 days postoperatively. Multivariate regression analysis was used to identify predictors for donor site complications. Variables found significant were used to construct machine learning models to predict donor site complications. Of 258 patients, 39 patients (15%) developed abdominal donor site complications, which included 19 cases of dehiscence, 12 cases of partial necrosis, 27 cases of infection, and 6 cases of seroma. On univariate regression analysis, age (p = 0.026), body mass index (p = 0.003), mean flap weight (p = 0.006), and surgery time (p = 0.035) were predictors of donor site complications. On multivariate regression analysis, age (p = 0.025), body mass index (p = 0.010), and surgery duration (p = 0.048) remained significant. Radiographic features of obesity, such as abdominal wall thickness and total fascial diastasis, were not significant predictors of complications (p > 0.05). In our machine learning algorithm, the logistic regression model was the most accurate at predicting donor site complications with the accuracy of 82%, specificity of 0.93, and negative predictive value of 0.87. This study demonstrates that body mass index is superior to radiographic features of obesity in predicting donor site complications following DIEP flap harvest. Other predictors include older age and longer surgery duration. Our logistic regression machine learning model has the potential to quantify the risk of donor site complications.

Novel Port Placement in Robot-Assisted DIEP Flap Harvest Improves Visibility and Bilateral DIEP Access: Early Controlled Cohort Study.

To minimize donor-site damage, robot-assisted (RA) deep inferior epigastric perforator (DIEP) flap harvest has been suggested. Current robotic approaches favor port placement, which either does not allow a bilateral DIEP flap harvest through the same ports or necessitates additional scars. In this article, the authors propose a modification of port configuration. In a retrospective controlled cohort study, RA-DIEP and conventional DIEP surgery were compared. The perforator and pedicle were visualized conventionally until the level behind the rectus abdominis muscle. Next, the robotic system was installed to dissect the retromuscular pedicle. The authors assessed patient age; body mass index; history of smoking, diabetes mellitus, and hypertension; and additional surgical time. The length of the anterior rectus sheath (ARS) incision was measured. Pain was quantified using the visual analogue scale. Donor-site complications were assessed. Thirteen RA-DIEP flaps (11 unilateral and two bilateral) and 87 conventional DIEP flaps were harvested without flap loss. The bilateral DIEP flaps were raised without readjustments of the ports. The mean time for pedicle dissection was 53.2 ± 13.4 minutes. The length of the ARS incision was significantly shorter in the RA-DIEP group (2.67 ± 1.13 cm versus 8.14 ± 1.69 cm; 304.87% difference; P < 0.0001). There was no statistical difference in postoperative pain (day 1: 1.9 ± 0.9 versus 2.9 ± 1.6, P = 0.094; day 2: 1.8 ± 1.2 versus 2.3 ± 1.5, P = 0.319; day 3: 1.6 ± 0.9 versus 2.0 ± 1.3, P = 0.444). Preliminary results show that the authors' RA-DIEP approach is safe and allows dissection of bilateral RA-DIEP flaps with short ARS incision lengths. Therapeutic, III.

Short Fasciotomy-Deep Inferior Epigastric Perforator Flap Harvest for Breast Reconstruction.

Despite several technical modifications to further reduce donor invasiveness in harvesting deep inferior epigastric perforator (DIEP) flaps, techniques with general applicability and demonstrating clinical benefits are scarce. The present study aimed to introduce a short-fasciotomy technique and evaluate its reliability, efficacy, and applicability by comparison with those of conventional methods. A retrospective study was conducted with 304 consecutive patients who underwent DIEP flap-based breast reconstruction. A total of 180 patients underwent the conventional technique between October of 2015 and December of 2018 (cohort 1), and in 124 patients, the short-fasciotomy technique was implemented between January of 2019 and September of 2021 (cohort 2). In the short-fasciotomy technique, the rectus fascia was incised as much as overlies the intramuscular course of targeted perforators. After intramuscular dissection, pedicle dissection proceeded without additional fasciotomy. Postoperative complications and fasciotomy-saving benefits were compared. The short-fasciotomy technique was successfully adapted for all patients in cohort 2, regardless of length of intramuscular course and number of harvested perforators, with no case requiring conversion to the conventional technique. The mean fasciotomy incision length in cohort 2 was 6.6 cm, which was significantly shorter than that in cohort 1 (11.1 cm). The mean length of the harvested pedicle in cohort 2 was 12.6 cm. No flap loss occurred in either group. The rate of other perfusion-related complications did not differ between the two groups. The rate of abdominal bulge/hernia was significantly lower in cohort 2. The short-fasciotomy technique allows for less invasive DIEP flap harvest regardless of anatomical variability. It provides reliable outcomes with minimal functional donor-site morbidity. Therapeutic, III.

The ideal scenario in deep inferior epigastric perforator (DIEP) flap dissection: a complete muscle and nerve-sparing approach

The deep inferior epigastric perforator flap (DIEP) has become the gold standard method of autologous breast reconstruction by simultaneously maximising aesthetics of the breasts and abdomen, and maximising the function of the abdominal wall. While the anatomical variability of the DIEP flap perforators have been well characterised, there has been less attention paid to the hierarchy of DIEP perforators in terms of limiting abdominal dysfunction post-operatively. In this paper, we seek to draw attention to what is, in our opinion, the ideal scenario in DIEP flap harvest. Where present, a medial paramuscular cutaneous vessel (MPCV) may be harvested using the pyramidalis separation technique enabling a complete rectus abdominis muscle-sparing and abdominal motor nerve-sparing approach. Herein, we describe the pyramidalis separation technique and the results in representative cases. In our experience, this technique enables an expeditious surgical procedure, and dramatically reduces damage to both muscles and nerves.Level of evidence: Level V, therapeutic study

Midline epigastric scars can be associated with higher umbilical complications following DIEP flap harvest

Umbilical complications can be relatively common after breast reconstruction with deep inferior epigastric perforator (DIEP) flaps. The medial umbilical ligaments and the ligamentum teres hepatis can be the sole blood supply to the umbilicus after a DIEP flap harvest. Prior incisions along the epigastric midline may disrupt the ligamentum teres hepatis. In this retrospective study, we assess the influence of previous midline epigastric scars on umbilical complications after DIEP flap harvest. All patients who underwent breast reconstruction with DIEP flaps were identified at an academic institution over six years. Relevant sociodemographic and clinicopathologic factors were reviewed in the electronic medical records. Univariate and multivariate analyses were performed to determine the role of clinical variables to predict the chance of umbilical complications. A total of 243 patients met inclusion criteria, with 39 patients (16%) having prior surgery utilizing midline epigastric incisions. Twenty-one patients had umbilical complications. No significant difference in patient characteristics was found between patients with and without prior midline epigastric scars. Patients with a history of previous midline epigastric scars had a higher rate of umbilical complications (20.5% vs. 6.4%, p < 0.01). Bilateral medial row perforator-based DIEP flap harvest was also related to a higher rate of umbilical complications (18.4% vs. 6.2% p < 0.01). Previous midline epigastric scars are associated with higher rates of umbilical complications after DIEP flap harvest. Bilateral medial row perforator-based DIEP flap harvest exacerbates the rate of umbilical complications and should be avoided in patients with prior midline epigastric incision whenever possible.

Holographic Augmented Reality for DIEP Flap Harvest.

During a deep inferior epigastric perforator (DIEP) flap harvest, the identification and localization of the epigastric arteries and its perforators are crucial. Holographic augmented reality is an innovative technique that can be used to visualize this patient-specific anatomy extracted from a computed tomographic scan directly on the patient. This study describes an innovative workflow to achieve this. A software application for the Microsoft HoloLens was developed to visualize the anatomy as a hologram. By using abdominal nevi as natural landmarks, the anatomy hologram is registered to the patient. To ensure that the anatomy hologram remains correctly positioned when the patient or the user moves, real-time patient tracking is obtained with a quick response marker attached to the patient. Holographic augmented reality can be used to visualize the epigastric arteries and its perforators in preparation for a deep inferior epigastric perforator flap harvest. Potentially, this workflow can be used visualize the vessels intraoperatively. Furthermore, this workflow is intuitive to use and could be applied for other flaps or other types of surgery.

Partial DIEP flap loss in a patient with history of abdominal liposuction

Classically, history of prior abdominal liposuction has been considered a relative contraindication for breast reconstruction using deep inferior epigastric perforator (DIEP) flap. The rationale for this is based on the fact that liposuction can possibly damage perforating vessels, which could compromise flap survival. However, multiple recently published reports have shown that imaging using CT angiography or colour Duplex ultrasonography could be used to accurately assess the adequacy of the perforating vessels before DIEP flap harvest. This contraindication is currently being reconsidered in the scientific literature. We present a case of partial DIEP flap loss in a patient with history of abdominal liposuction that happened despite preoperative identification of adequate perforators using CT angiography and intraoperative clear evidence of patent anastomoses. This occurrence reopens in our view the question of whether DIEP flaps can be safely performed on patients with a history of abdominal liposuction, even in the presence of adequate perforators on regular CT angiography or Doppler ultrasonography. While abdominal liposuction may not injure perforating vessels, its detrimental effect on linking micro-vessels within the flap cannot be fully evaluated using CT Angiography. Therefore, the use of another imaging modality, such as the indocyanine green laser angiography, to assess perfusion before DIEP flap harvesting is performed and could be considered in patients with history of abdominal liposuction.

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.

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.

Indocyanine Green Angiography for Continuously Monitoring Blood Flow Changes and Predicting Perfusion of Deep Inferior Epigastric Perforator Flap in Rats

Background Deep inferior epigastric perforator (DIEP) flap approach has excellent outcomes and low morbidity. However, it is associated with high rates of perfusion-related complications. To observe the blood flow changes and the stages of the flap perfusion, as well as the necrosis formation, we used indocyanine green (ICG) to monitor its perforators before and after DIEP flap harvesting. Methods: Abdominal perforator flaps supplied by the right superior abdominal perforating arteries were generated from seven SD rats. Laser-assisted ICG angiography was applied for dynamical and continuous observation of changes in the blood flow and courses of flap perfusion. Areas of flap perfusion were quantitatively analyzed using ImageJ. Results: The average perfusion area of the seven flaps after surgery and at days 1, 2, and 3 after surgery were 23.06 ± 2.47, 22.48 ± 2.04, 28.34 ± 1.14, and 28.97 ± 2.44 cm2, respectively. Compared to values after surgery, no significant difference was observed on day one (p > 0.05); however, the flaps had significantly improved perfusion areas on day 2 (mean value of 5.28 ± 1.83 cm2, p < 0.01) and day 3 (mean value of 5.91 ± 2.60 cm2, p < 0.01) postsurgery. In addition, there were no significant differences between days 2 and 3 (p > 0.05). The blood flow changes in both arteries and veins, the stages of flap perfusion, and the development of necrosis at the distal end of the flap were also observed. Conclusion: We gained valuable knowledge on the dynamic of blood flow changes and the course of flap perfusion inside the DIEP flap. Dynamic and continuous observation with ICG angiography through an SPY system is a powerful method for monitoring of blood supply in flaps that can be used to predict flap perfusion with a strong positive predictive significance.

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.

Successful Deep Inferior Epigastric Perforator Flap Breast Reconstruction Following Prior Deep Inferior Epigastric Source Vessel Ligation

INTRODUCTION: Deep inferior epigastric perforator (DIEP) flaps represent an excellent method of breast reconstruction. Its success is predicated upon careful dissection of the dominant deep inferior epigastric (DIE) perforators and the patency of its associated source vessels. Prior ligation of the DIE vessels would thereby negatively impact DIEP flap harvest. If collateral branches maintain the patency of these source vessels, DIEP flap harvest may still be possible. We have successfully performed two bilateral DIEP breast reconstructions following prior ligation of the DIE source vessels. METHODS: A retrospective review of two cases of DIEP breast reconstruction was performed following prior ligation of the DIE source vessels. The characteristics and findings in these specific cases were analyzed. RESULTS: The first patient had multiple failed attempts at bilateral breast reconstruction using implants and latissimus flaps. The right chest wall had been previously radiated. A bilateral salpingo-oophorectomy had been performed for ovarian carcinoma via a Pfannenstiel incision. The DIE source vessels were found to be ligated and transected bilaterally from her gynecologic procedure near their origin at the iliac vessels. Although diminutive in size, intercostal collaterals near the hemoclips maintained source vessel patency and bilateral DIEP reconstruction was completed. The second patient had prior latissimus-based breast reconstructions with submuscular implants. This was complicated by a right-sided infected seroma and bilateral implant capsular contracture. She had undergone a prior delay procedure for possible pedicled TRAM flap reconstruction but did not wish to sacrifice her rectus muscles. CT angiography was performed of the abdomen and pelvis for possible gluteal artery perforator flap reconstruction. Despite clips on the DIE vessels near their origin, they appeared patent and of suitable caliber with sufficient length for bilateral breast reconstruction. Bilateral DIEP breast reconstruction was successfully performed without any associated complications. CONCLUSION: Successful DIEP flap reconstruction depends upon the patency of the DIE source vessels and sufficient perforators to maintain normal flap perfusion. Prior ligation of the DIE source vessels would therefore negatively impact successful flap harvest. If, however, collateral vessels maintain the patency of these source vessels, DIEP flap reconstruction can thereby be carried out successfully as demonstrated by these two cases. Radiologic imaging can aid in identifying such cases.

Epigastric hernia following DIEP flap breast reconstruction: Complication or coincidence?

Donor site hernias are a rare but well recognised complication of deep inferior epigastric perforator (DIEP) flap breast reconstruction but there are no reported cases of epigastric hernias after such surgery. We report three patients who developed symptomatic epigastric hernias within 2-8 months after discharge from follow-up. Patients who were referred to the Breast Plastic Surgery Clinic with symptomatic epigastric hernias following DIEP flap breast reconstruction were retrospectively reviewed. The three patients were aged between 50 and 70 years. Their mean BMI was 29 and none were smokers or diabetic. The incidences of other predisposing factors were: previous abdominal surgery (1/3), heavy lifting (2/3) and multiparity (2/3). They were successfully treated laparoscopically (2) or by open technique (1) confirming the CT scan findings. The aetiology of epigastric hernias is obscure in general. The association with DIEP flap harvest may be purely coincidental. However, it appears that abdominal flap harvest predisposed these patients to epigastric hernias. One or more of the following factors may have caused either weakness of the anterior abdominal wall or increased intraabdominal pressure: * Short-term partial denervation of the rectus abdominis muscle; * Heavy lifting; * Previous surgery; obesity; multiple pregnancies; * Tight plication of the infraumbilical rectus sheath and muscle. This series of 3 symptomatic epigastric hernias following DIEP flap breast reconstruction is interesting as it documents donor site morbidity at a site distant from the exact site of flap harvest; this subject merits further detailed investigation.