Free Deep Inferior Epigastric Perforator Flap Research Articles

1211 Patterns of Recurrences After Mastectomy for Invasive Breast Cancer and DCIS Followed by Immediate Breast Reconstruction: 13-Year Follow-Up from a Single institution

Abstract Aim A retrospective review was conducted at a single centre to analyse the patterns of recurrence in IBR. Method Between January 2009 and December 2021, 347 patients who had IBR for either invasive (244) or DCIS (125), were analysed retrospectively. The study included patients who received implants without ADM (10.8%), ADM with +implant (69%), Latissimus Dorsi flap +/- implant (18.1%), and deep inferior epigastric perforator-free flaps (2.5%). Results During the study period, 29 patients developed recurrence over a median period of 74 months (ranging from 24 to 125 months). Two patients had local cancer recurrence only (0.5%), 5 patients had local recurrence associated with distant or regional metastasis, (1.4%) and 19 cases with distal metastasis were identified (8.3%). The study found an overall survival rate of 96.4% and a disease-free survival rate of 91.7%. The most familiar sites of recurrence in breast cancer are distal recurrence, (Bone being the most common site), followed by local recurrence. Discussion This rate is in line with the expected range, assuming a standard of recurrence of 1% per year. Nevertheless, it is crucial to acknowledge the possibility of selection bias, as patients with advanced diseases and significant comorbidities may not have been offered IBR. Conclusions Based on the findings of the study, it can be inferred that mastectomy with (IBR) is a safe option for mastectomy.

Abdominal donor-site complications following autologous breast reconstruction: A multi-institutional multisurgeon study

BackgroundThe deep inferior epigastric perforator (DIEP) free flap is the gold standard procedure for autologous breast reconstruction. Although breast-related complications have been well described, donor-site complications and contributing patient risk factors are poorly understood. MethodsWe examined a multi-institutional, prospectively maintained database of patients undergoing DIEP free flap breast reconstruction between 2015 and 2020. We evaluated patient demographics, operative details, and abdominal donor-site complications. Logistic regression modeling was used to predict donor-site outcomes based on patient characteristics. ResultsA total of 661 patients were identified who underwent DIEP free flap breast reconstruction across multiple institutions. Using logistic regression modeling, we found that body mass index (BMI) was an independent risk factor for umbilical complications (odds ratio [OR] 1.11, confidence interval [CI] 1.04–1.18, p = 0.001), seroma (OR 1.07, CI 1.01–1.13, p = 0.003), wound dehiscence (OR 1.10, CI 1.06–1.15, p = 0.001), and surgical site infection (OR 1.10, CI 1.05–1.15, p = 0.001) following DIEP free flap breast reconstruction. Further, immediate reconstruction decreases the risk of abdominal bulge formation (OR 0.22, CI 0.108–0.429, p = 0.001). Perforator selection was not associated with abdominal morbidity in our study population. ConclusionsHigher BMI is associated with increased abdominal donor-site complications following DIEP free flap breast reconstruction. Efforts to lower preoperative BMI may help decrease donor-site complications.

Inset techniques for the DIEP flap - what improves aesthetic outcomes?

The deep inferior epigastric perforator (DIEP) flap is widely considered as the gold standard in breast reconstruction. The inset technique of the DIEP flap is crucial in determining the overall aesthetic outcome; however, to date no systematic review is available that comprehensively assesses the various techniques. Evaluation of topic: A systematic review was performed according to the PRISMA guidelines. The methodology is outlined within our published protocol (Prospero CRD42023449477). Included articles met a minimal criterion compromising of the intervention (DIEP free flap for breast reconstruction) and outcomes (aesthetic and clinical outcomes). Six articles were included in this review, with a total of 346 patients and a follow-up ranging from 6 months to 4 years. Four articles were of a prospective case series study design, one article was a randomized controlled trial, and one article was a case-control study. The risk of bias was assessed to be high in the case series, but low and moderate in the randomized controlled trial and case-control study respectively. Although limited by the quality of the evidence, the single aesthetic unit principle, dual-plane inset, elimination of the need for a skin paddle, appropriate flap positioning and rotation, and algorithmic in-setting may all improve the aesthetic outcome of DIEP free flaps.

Improved Operative Efficiency and Surgical Times in Autologous Breast Reconstruction: A 15-year Single-center Retrospective Review.

Autologous breast reconstruction using a free deep inferior epigastric perforator (DIEP) flap is a complex procedure that requires a dedicated approach to achieve operative efficiency. We analyzed data for DIEP flaps at a single center over 15 years to identify factors contributing to operative efficiency. A single-center, retrospective cohort analysis was performed of consecutive patients undergoing autologous breast reconstruction using DIEP free flaps between January 1, 2005, and December 31, 2019. Data were abstracted a priori from electronic medical records. Analysis was conducted by a medical statistician. Analysis of 416 unilateral and 320 bilateral cases (1056 flaps) demonstrated reduction in operative times from 2005 to 2019 (11.7-8.2 hours for bilateral and 8.4-6.2 hours for unilateral, P < 0.000). On regression analysis, factors significantly correlating with reduced operative times include the use of venous couplers (P < 0.000), and the internal mammary versus the thoracodorsal recipient vessels (P < 0.000). Individual surgeon experience correlated with reduced OR times. Post-operative length of stay decreased significantly, without an increase in 30-day readmission or emergency presentations. Flap failure occurred in two cases. Flap take-back rate was 2% (n = 23) with no change between 2005 and 2019. Operative times for breast reconstruction have decreased significantly at this center over 15 years. The introduction of venous couplers, use of the internal mammary system, and year of surgery significantly correlated with decreased operative times. Surgeon experience and a shift in surgical workflow for DIEP flap reconstruction likely contributed to the latter finding.

Surgical Considerations of One-Stage Reconstruction of Large Extremity Defects Using a Thin Deep Inferior Epigastric Perforator Flap.

Background One-stage reconstruction with "thin perforator flaps" has been attempted to salvage limbs and restore function. The deep inferior epigastric perforator (DIEP) flap is a commonly utilized flap in breast reconstruction (BR). The purpose of this study is to present the versatility of DIEP flaps for the reconstruction of large defects of the extremities. Methods Patients with large tissue defects on extremities who were treated with thin DIEP flaps from January 2016 to January 2018 were included. They were minimally followed up for 36 months. We analyzed the etiology and location of the soft tissue defect, flap design, anastomosis type, outcome, and complications. We also considered the technical differences in the DIEP flap between breast and extremity reconstruction. Results Overall, six free DIEP flaps were included in the study. The flap size ranged from 15 × 12 to 30 × 16 cm 2 . All flaps were transversely designed similar to a traditional BR design. Three flaps were elevated with two perforators. Primary closure of the donor site was possible in all cases. Five flaps survived with no complications. However, partial necrosis occurred in one flap. Conclusion A DIEP flap is not the first choice for soft tissue defects, but it should be considered for one-stage reconstruction of large defects when the circulation zone of the DIEP flap is considered. In addition, this flap has many advantages over other flaps such as provision of the largest skin paddle, low donor site morbidity with a concealed scar, versatile supercharging technique, and a long pedicle.

Should Sickle Cell Trait Be a Contraindication to Breast Reconstruction?—A Case Series Analysis

Abstract Background While sickle cell disease has long been considered a contraindication to breast free flap reconstruction, there have been less definitive decisions about the impact of sickle cell trait on these procedures. We sought to analyze the patients with sickle cell trait who underwent free deep inferior epigastric perforator (DIEP) flap and pedicled latissimus dorsi (LD) flap at a single institution to determine the reconstructive outcomes. Methods Patients with sickle cell trait who underwent breast free DIEP and pedicled LD reconstruction from 2007 to 2021 at a single institution by the lead surgeon were analyzed for demographics and surgical outcomes. Results Four patients were identified as having sickle cell trait and having undergone a breast flap reconstruction. The average age of the patients was 54 years, median body mass index was 25, and past medical history was notable for one patient being a current smoker, and one patient having hypertension. Two patients received a unilateral free DIEP flap, one received a bilateral free DIEP flap, and one received a unilateral pedicled LD flap for a total of five flaps in four patients. Three of the patients received prior hormone therapy, one received prior radiation therapy, and one received prior chemotherapy. There were no instances of flap failure, vessel thrombosis, pulmonary embolism, or deep venous thrombosis. One patient experienced wound dehiscence. Conclusion In this case series we present four patients with sickle cell trait who successfully underwent breast flap reconstruction without any instances of flap or systemic thrombosis. More work is needed to determine how to pre- and postoperatively optimize patients with sickle cell trait for favorable breast flap reconstruction outcomes.

Reconstruction of chronic radiation-induced ulcers in the chest wall using free and pedicle flaps.

Resection of radiation-induced ulcers often causes full-thickness defects of the chest wall. We retrospectively reviewed and evaluated 17 patients to explore a method of chest wall reconstruction. A total of 17 breast cancer patients with radiation-induced ulcers were included. Various type of prostheses and flaps were used, results of clinic were evaluated. Sixteen patients had full-thickness defects and one patient had only a soft tissue defect and underwent reconstruction with a pedicle latissimus dorsi (LD) myocutaneous flap. Among all 16 full-thickness defect cases, 15 patients underwent bony thoracic reconstruction using polymesh/3D-printed titanium plates or methyl methacrylate. For soft tissue reconstruction, 13 patients reconstruction using a free deep inferior epigastric perforator (DIEP) flap in combination with a contralateral transverse rectus abdominis myocutaneous (TRAM) flap, and 2 underwent pure free DIEP flap reconstruction. Among all the patients 15 healed with no complications, and 2 patients had delayed healing on the edges of the flaps. Distant pedicle or free flap can used for soft tissue defect coverage, for those severe patients with full-thickness defects and used prostheses, free deep inferior epigastric perforator flap in combination with a contralateral transverse rectus abdominis myocutaneous flap (TRAM + DIEP) would be an applicable choice.

Clinical outcomes of intraoperative dopamine infusion for hypotensive patients during breast reconstruction with deep inferior epigastric perforator (DIEP) flaps

Dopamine has a favorable therapeutic profile but has not been widely used to treat hypotension during microvascular breast reconstruction. The purpose of this study was to evaluate outcomes in patients who received dopamine during breast reconstruction using deep inferior epigastric perforator (DIEP) free flaps and compare them with patients who did not receive dopamine. A single-center retrospective review was performed for patients who underwent breast reconstruction with DIEP free flaps between October 2018 and March 2020. Patient demographics, comorbidities, fluid balance, hospital stay, and adverse outcomes were compared between patients who received at least 1 h of dopamine (DA) and patients who did not receive dopamine (ND). Subgroup analyses were performed for bilateral procedures and patients who received dopamine. Twenty-five patients in the DA group and 43 patients in the ND group met the inclusion criteria. There were no flap-related complications. Patients who had dopamine initiated to maintain blood pressures had a higher total volume of intravenous fluid (ND:3.81L vs. DA:5.04L, p=0.005). However, DA patients exhibited decreased fluid requirements (ND:839 mL/h vs. DA:479 mL/h, p=0.004) and increased urine output (ND:98.0 mL/h vs. DA:340 mL/h, p=<0.001) once dopamine was initiated. Intraoperative urine output (ND:1.37 L vs. DA:3.48 L, p<0.001) and rate (ND:1.9 ml/kg/h vs. DA:3.7 ml/kg/h, p<0.001) were increased in the DA group. The fluid balance of patients undergoing bilateral procedures was closer to neutral for patients who received dopamine (ND:+3.43 L vs. DA:+2.26 L, p=0.03). Dopamine is safe to use in microvascular breast reconstruction. It may be beneficial for hemodynamically labile patients by stabilizing blood pressure and facilitating a neutral fluid balance.

Intraoperative Blood Flow Analysis of DIEP vs. ms-TRAM Flap Breast Reconstruction Combining Transit-Time Flowmetry and Microvascular Indocyanine Green Angiography.

Background: Vascular patency is the key element for high flap survival rates. The purpose of this study was to assess and compare the blood flow characteristics of deep inferior epigastric perforator (DIEP) and muscle-sparing transverse rectus abdominis musculocutaneous (ms-TRAM) flaps for autologous breast reconstruction. Methods: This prospective clinical study combined Transit-Time Flowmetry and microvascular Indocyanine Green Angiography for the measurement of blood flow volume, vascular resistance, and intrinsic transit time. Results: Twenty female patients (mean age, 52 years) received 24 free flaps (14 DIEP and 10 ms-TRAM flaps). The mean arterial blood flow of the flap in situ was 7.2 ± 1.9 mL/min in DIEP flaps and 11.5 ± 4.8 mL/min in ms-TRAM flaps (p < 0.05). After anastomosis, the mean arterial blood flow was 9.7 ± 5.6 mL/min in DIEP flaps and 13.5 ± 4.2 mL/min in ms-TRAM flaps (p = 0.07). The arterial vascular resistance of DIEP flaps was significantly higher than that of ms-TRAM flaps. The intrinsic transit time of DIEP flaps was 52 ± 18 s, and that of ms-TRAM flaps was 33 ± 11 s (p < 0.05). The flap survival rate was 100%. One DIEP flap with the highest intrinsic transit time (77 s) required surgical revision due to arterial thrombosis. Conclusion: In this study, we established the blood flow characteristics of free DIEP and ms-TRAM flaps showing different blood flow rates, vascular resistances, and intrinsic transit times. These standard values will help to determine the predictive values for vascular compromise, hence improving the safety of autologous breast reconstruction procedures.

Free-flap breast reconstruction: cost analysis in the Swiss healthcare system

Breast cancer is the most common type of malignancy among women. Mastectomy maintains an essential role in oncological therapy and led to the development of breast reconstruction procedures. The deep inferior epigastric perforator (DIEP) free flap became in the last decade a popular approach for breast reconstruction. Although this procedure is known to be more complex than other techniques, it offers one of the highest patient satisfaction rates. However, the cost-effectiveness of this technique has rarely been assessed; and the real cost coverage by health insurance has never been studied. This study estimated the real cost of immediate DIEP free flap breast reconstruction after unilateral mastectomy and evaluated the cost coverage by healthcare insurers according to the diagnosis-related group (DRG) reimbursement scheme in Switzerland. Medical files of 20 consecutive patients who underwent immediate DIEP free-flap breast reconstruction between 2012 and 2017 were reviewed retrospectively. Billing data according to DRG rates were compared with an estimation of the real cost generated by the procedure. The mean charge according to the DRG model for one-stage DIEP free-flap reconstruction was CHF 29,573 (CHF 19,256–64,741). The mean real estimated cost was CHF 33,416 (CHF 20,633–47,036). Seven different DRG codes were used between 2012 and 2017, each offering a different definition and compensation. The DRG pricing scheme evolves through annual revisions. Progressively, more specific codes were created and used, allowing a better cost coverage for the procedure. Since 2017, the use of the dedicated code J01B has resulted in adequate cost coverage of the procedure. Since it has been widely accepted that DIEP breast reconstruction has advantages such as high patient satisfaction, we encourage the inclusion of this procedure in the reconstructive arsenal of breast cancer centres in Switzerland.

Impact of body mass index on free DIEP flap breast reconstruction: A multicenter cohort study

Several patient-related factors have been identified with regard to the safety and efficacy of breast reconstructions. This study analyzed the largest series of microsurgical breast reconstructions in Germany using deep inferior epigastric perforator (DIEP) flaps, with a focus on the impact of patient body mass index (BMI). A total of 3911 female patients underwent 4561 free DIEP flap breast reconstructions across 22 different centers. The cases were divided into five groups using World Health Organization BMI criteria: underweight group (BMI <18.5 kg/m2), normal weight/ control group (BMI: 18.5-24.9 kg/m2), overweight group (BMI: 25-29.9 kg/m2), moderately obese group (BMI: 30-34.9 kg/m2), and severely obese group (BMI ≥ 35 kg/m2). Surgical complications were accounted for and the five BMI groups were then compared. Overall, there was no significant difference regarding the rate of partial- and total flap loss between all BMI groups (p>0.05). However, overweight and obese patients showed significantly higher rates of postoperative infections at the donor and recipient sites than the control group (donor site infections: overweight 0.6%; moderately obese 0.9%; severely obese 2.4% vs control 0.1%; all p<0.01; recipient site infections: overweight 0.5%; moderately obese 0.8%; severely obese 1.4% vs control 0.1%; all p<0.05). The rate of medical complications also differed significantly between groups, with the highest rates in moderately and severely obese women (moderately obese: 8.4%; severely obese: 13.0% vs. control: 5.1%; p<0.01). Our findings suggest that successful free tissue transfer can be achieved even in an underweight and severely obese population with acceptable risk for complications.

Photoplethysmography in postoperative monitoring of deep inferior epigastric perforator (DIEP) free flaps

Objective: Deep inferior epigastric perforator (DIEP) free flaps are widely used as a reconstruction option following mastectomy in breast cancer. During such cases partial tissue necrosis can occur due to the insufficient blood supply to the transplanted tissue site. Therefore, monitoring of flap perfusion and early detection of flap failure is a prerequisite to flap survival. There is a need to develop a non-invasive, easy to use, reproducible and inexpensive monitoring device to assess flap perfusion postoperatively. Approach: A three-wavelength reflective optical sensor and processing system based on the principle of photoplethysmography (PPG) has been developed to investigate blood volumetric changes and estimate free flap blood oxygen saturation continuously and non-invasively in DIEP free flaps in the postoperative period. The system was evaluated in 15 patients undergoing breast reconstructive surgery using DIEP free flap. Main results and Significance: Good quality red, infrared and green PPG signals were obtained in the postoperative period. Initial estimation of blood oxygen saturation values estimated from the free flap PPGs seem to be in broad agreement with the commercial finger pulse oximeter used in this study. This pilot study has demonstrated that PPG has the potential to be used as a monitoring technique in assessing free flap viability.

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.

Use of Muscle Feeding Arteries as Recipient Vessels for Soft Tissue Reconstruction in Lower Extremities.

Microsurgical free tissue transfer is still playing an important role in lower extremity reconstruction. Finding a suitable recipient artery for anastomosis is critical in the microsurgical procedure, especially in an extensive wound, or in a complex trauma combined with vascular injury. From April 2014 to March 2018, we retrospectively reviewed patients with traumatic/post-traumatic, oncologic, and electrical wounds in the lower extremity. Those treated with muscle feeding artery as recipient vessels were included. The latissimus dorsi (LD) muscle free flap, anterior lateral thigh (ALT) perforator free flap, and deep inferior epigastric perforator (DIEP) free flap were raised. The muscle feeding arteries to vastus lateral muscle and to medial head of gastrocnemius muscle, concomitant veins, and great saphenous vein were used as recipient vessels. Injuries included in the study were caused by tumour in 2 cases, car accident in 3 cases, crushing in 3 cases, burns in one case, and electrical injury in one case. The wound size varied from 14 cm × 6 cm to 30 cm × 20 cm. LD, ALT, and DIEP free flaps were used in 6, 3, and 4 patients, respectively. The muscle feeding arteries to medial head of gastrocnemius muscle, to sartorius muscle, and to vastus lateral muscle were used as recipient arteries in 4, 5, and one patient, respectively. Concomitant and great saphenous veins were used as recipient veins in 10 and 4 patients, respectively. Using the muscle feeding artery is feasible to avoid injury to the main artery and facilitate dissection and anastomoses, particularly when the wound is located proximal to the mid-third of the lower leg.

Diametric Comparison between the Thoracodorsal Vessel and Deep Inferior Epigastric Vessel in Breast Reconstruction

Background In microvascular anastomosis, size discrepancy is common and can increase thrombotic complications. If size differences can be predicted, then vessels of the appropriate size can be selected. This study documented the difference in diameter between the thoracodorsal (TD) vessel and deep inferior epigastric perforator (DIEP) pedicle in each patient who underwent breast reconstruction using free tissue transfer. Patients and Methods. This retrospective study included 32 anastomoses (27 breasts including five cases of supercharged anastomosis) of breast reconstruction with the free DIEP flap and TD recipient between August 2018 and June 2019. In the microscopic view, the caliber of the TD vessel, the largest branch to the serratus anterior muscle, the descending branch, the largest and the second largest branches to the latissimus dorsi muscle, and the DIEP pedicle were measured. Results The diameter of the deep inferior epigastric artery was similar to that of the descending branch, and their anastomosing rate was 56.3%. The diameter of the deep inferior epigastric vein was similar to the branch to the serratus anterior muscle and the descending branch, and their anastomosing rates were 29.3% and 29.3%, respectively. All flaps were survived; however, in one case, a reoperation was needed to remove the hematoma, in which case fat necrosis occurred as the only complication. Conclusion TD branches of similar size to the DIEP pedicle were prioritized in anastomosis. The descending branch and the branch to the serratus anterior muscle are expected to be good candidates as recipients in breast reconstruction with DIEP free flap. Moreover, supercharged anastomosis of DIEP pedicles can be achieved within TD branches.

Salvage of late flap compromise in deep inferior epigastric perforator flaps: To revise or not to revise

Although the success rate of deep inferior epigastric perforator (DIEP) flaps has increased, late flap failures still occur and have a low salvage rate. The present article describes a case of salvage of a case of late flap failure using the pedicle vein as a vein graft source. A 50-year-old woman underwent a bilateral DIEP free flap procedure. On postoperative day 6, she experienced flap compromise and underwent emergency flap revision. In the flap revision, flap venous drainage and the superficial inferior epigastric vein were completely obstructed. A Fogarty catheter was used to remove a thrombus from the completely obstructed pedicle vein, and this pedicle vein was used as a graft source and was ligated in retrograde fashion to the flap vein stump. After injection of urokinase into the arterial branch, venous flow to the flap was restored. At a 6-month follow-up visit in the outpatient clinic, only partial fat necrosis at the flap was noted. By dissecting various perforators in the initial operation, decisions regarding immediate revision can be made with more confidence. Additionally, the combined procedures performed in this case may be helpful even for practitioners treating cases of late flap compromise.

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.

Dynamic infrared thermography (DIRT) in Deep Inferior Epigastric Perforator (DIEP) flap breast reconstruction: standardization of the measurement set-up.

Breast reconstruction with an autologous free Deep Inferior Epigastric Perforator (DIEP) flap is one of the preferred options following mastectomy. A challenging step in this procedure is the selection of a suitable perforator that provides sufficient blood supply for the flap. The current golden standard for perforator mapping is computed tomography angiography (CTA). However, this is a relatively expensive imaging modality that requires intravenous contrast injection and exposes patients to ionizing radiation. More recently, dynamic infrared thermography (DIRT) has been proposed as an alternative imaging modality for perforator identification. DIRT appears to be an ideal alternative technique not only for the identification of the dominant perforators, but also for the mapping of the individual influence of each perforator on the flap perfusion. Multiple studies have been performed with the use of DIRT, unfortunately without standardisation of the measurement set-up. In this technical note we propose a standardised and reproducible measurement set-up for the use of DIRT during breast reconstructions with a free DIEP flap. This set-up can be used pre-, intra- and postoperatively. A standardised measurement set-up will improve the quality of measured data and ensure reproducibility.

A cost-effectiveness analysis of DIEP vs free MS-TRAM flap for microsurgical breast reconstruction.

The deep inferior epigastric perforator (DIEP) flap may be associated with less long-term donor-site morbidity compared with free muscle-sparing transverse rectus abdominis myocutaneous flap (MS-TRAM) flap. However, DIEP flaps may have longer operative time and higher rates of acute postoperative complications. We performed a cost-effectiveness analysis (CEA) that compared the long-term costs and patient-reported outcomes between the two flaps. A retrospective cohort of women who received free MS-TRAM or DIEP flap reconstruction between January 2008 and December 2012, with a minimum of 2-year follow-up, were recruited. Cost data of the primary reconstruction and any subsequent hospitalization due to complications from the reconstruction within 2 years were obtained. Each patient received a BREAST-Q questionnaire at 2 years post-reconstruction. In total, 227 patients (180 DIEP, 47 free MS-TRAM) were included. DIEP patients had significantly fewer abdominal hernia (P = 0.04). The adjusted-incremental cost-effectiveness ratios found that DIEP flap was more cost-effective to free MS-TRAM flap in the domains of "Physical Well-Being of the Abdomen" and "Satisfaction with Outcome." DIEP flap is the more cost-effective method of autologous breast reconstruction in the long-term compared with free MS-TRAM flap with respect to patient-reported abdominal well-being and overall satisfaction with the outcome.

Correction: Breast reconstruction with the free TRAM or DIEP flap - What is the current standard? - Consensus Statement of the German Speaking Working Group for Microsurgery of the Peripheral Nerves and Vessels

The most common donor-site for autologous breast reconstruction is the abdomen. Over the past several decades technical advances have resulted in the development of flaps that have been associated with a progressive decrease in abdominal wall morbidity. However, controversy exists related to the differences between muscle-sparing (MS)-TRAM and deep inferior epigastric perforator (DIEP) flaps. Hence, the question which approach should be considered standard of care remains unanswered. To address this question the current literature and published evidence was critically reviewed and discussed by an expert panel at the 39th Annual Meeting of the German-speaking Society for Micro surgery of the Peripheral Nerves and Vessels (DAM). Based on this discussion a consensus statement was developed that incorporates contemporary data regarding postoperative complication rate, donor site morbidity, as well as expert opinion regarding technical details in autologous breast reconstruction with free TRAM and DIEP flaps.