Epigastric Artery Perforator Flap Breast Research Articles

Concordance between preoperative computed tomography angiographic mapping and intraoperative perforator selection for deep inferior epigastric artery perforator flap breast reconstructions.

Preoperative imaging for perforator identification prior to a deep inferior epigastric artery perforator (DIEP) flap elevation for breast reconstruction has many advantages. Currently, computed tomography (CT) angiography provides good visualization of the perforators and their course, and is thus the imaging technique of choice. The primary aim of this study was to determine the concordance between the perforators identified preoperatively and the perforators ultimately selected intraoperatively, with a standardized protocol, in a single institution. Secondly, we wanted to compare our results with those of other, similar studies and, thirdly, to identify those factors that may lead to a higher concordance. A retrospective review was undertaken of a case series of 49 consecutive patients undergoing unilateral autologous breast reconstruction with a DIEP flap at the Gelre Hospital, in the Netherlands, over a 4-year period from 2013 to 2017. The preoperative identification and selection of perforator number and location with the aid of CT angiography scanning were compared to the intraoperative findings and preference. Our study revealed a concordance of 67.3% between one or more perforators advised preoperatively by the radiologist and chosen intraoperatively by the surgeon. We identified significant differences in our protocol compared to others. The study confirmed the benefit to both the patient and the surgeon when preoperative CT angiography is used. Scanning protocols may vary considerably and should thus be carefully scrutinized before future comparisons are made. Based on this study, the scanning range, method of selecting perforators and timing of image acquisition may have to be optimized for future prospective clinical trials.

Patient-Reported Outcomes for Deep Inferior Epigastric Artery Perforator Flap Breast Reconstruction in the Severely Obese

Patient-Reported Outcomes for Deep Inferior Epigastric Artery Perforator Flap Breast Reconstruction in the Severely Obese

DIEP Flap Breast Reconstruction in Patients with Breast Ptosis: 2-Stage Reconstruction Using 3-Dimensional Surface Imaging and a Printed Mold.

Background:Autologous breast reconstruction can be performed for breasts with ptosis to a certain extent, but if patients desire to correct ptosis, mastopexy of the contralateral breast is indicated. However, accurate prediction of post-mastopexy breast shape is difficult to make, and symmetrical breast reconstruction requires certain experience. We have previously reported the use of three-dimensional (3D) imaging and printing technologies in deep inferior epigastric artery perforator (DIEP) flap breast reconstruction. In the present study, these technologies were applied to the reconstruction of breasts with ptosis.Methods:Eight breast cancer patients with ptotic breasts underwent two-stage unilateral DIEP flap breast reconstruction. In the initial surgery, tissue expander (TE) placement and contralateral mastopexy are performed simultaneously. Four to six months later, 3D bilateral breast imaging is performed after confirming that the shape of the contralateral breast (post-mastopexy) is somewhat stabilized, and a 3D-printed breast mold is created based on the mirror image of the shape of the contralateral breast acquired using analytical software. Then, DIEP flap surgery is performed, where the breast mold is used to determine the required flap volume and to shape the breast mound.Results:All flaps were engrafted without any major perioperative complications during both the initial and DIEP flap surgeries. Objective assessment of cosmetic outcome revealed that good breast symmetry was achieved in all cases.Conclusions:The method described here may allow even inexperienced surgeons to achieve reconstruction of symmetrical, non-ptotic breasts with ease and in a short time. While the requirement of two surgeries is a potential disadvantage, our method will be particularly useful in cases involving TEs, i.e., delayed reconstruction or immediate reconstruction involving significant skin resection.

Seguridad y complicaciones en reconstrucción mamaria autóloga con colgajo DIEP: una revisión sistemática

Autologous free flap breast reconstruction may be associated with complications related to the flap and the donor site. Our objective was to evaluate the reported evidence on safety, complications and risk factors in patients undergoing deep inferior epigastric artery perforator flap (DIEP) breast reconstruction. A systematic review was conducted based on a Medline search for studies published between September 1995 and September 2015. Demographic data, flap dimensions and complication rates were recorded including total flap necrosis, partial flap necrosis and fat necrosis. A total of 34 clinical studies including 35 case series, 2,761 patients and 3,927 DIEP flaps were identified. The mean body mass index was higher than 24.5kg/m2 whereas the obesity rate was above 14.5%. None of the articles reported flap weight, area or volume after molding. Total and partial flap necrosis rates were 1.9% (75/3,811) and 2.6% (68/2,575), respectively. Fat necrosis was diagnosed in 8.2% (308/3,746) of flaps with a standard deviation of 6.9. Reoperation was required in 5.5% (107/1,940) of the flaps. The incidence of hematoma in the recipient site and abdominal hernia or bulge formation was 3% (59/1,952 flaps and 52/1,725 patients). In conclusion, the occurrence of complications in breast reconstruction by autologous DIEP flap was low, although the occurrence of fat necrosis ranged widely.

An innovative method of planning and displaying flap volume in DIEP flap breast reconstructions

Determining the ideal volume of the harvested flap to achieve symmetry in deep inferior epigastric artery perforator (DIEP) flap breast reconstructions is complex. With preoperative imaging techniques such as 3D stereophotogrammetry and computed tomography angiography (CTA) available nowadays, we can combine information to preoperatively plan the optimal flap volume to be harvested. In this proof-of-concept, we investigated whether projection of a virtual flap planning onto the patient's abdomen using a projection method could result in harvesting the correct flap volume. In six patients (n=9 breasts), 3D stereophotogrammetry and CTA data were combined from which a virtual flap planning was created comprising perforator locations, blood vessel trajectory and flap size. All projected perforators were verified with Doppler ultrasound. Intraoperative flap measurements were collected to validate the determined flap delineation volume. The measured breast volume using 3D stereophotogrammetry was 578±127cc; on CTA images, 527±106cc flap volumes were planned. The nine harvested flaps weighed 533±109g resulting in a planned versus harvested flap mean difference of 5±27g (flap density 1.0g/ml). In 41 out of 42 projected perforator locations, a Doppler signal was audible. This proof-of-concept shows in small numbers that flap volumes can be included into a virtual DIEP flap planning, and transferring the virtual planning to the patient through a projection method results in harvesting approximately the same volume during surgery. In our opinion, this innovative approach is the first step in consequently achieving symmetric breast volumes in DIEP flap breast reconstructions.

Predicting and planning for SIEA flap utilisation in breast reconstruction: An algorithm combining pre-operative computed tomography analysis and intra-operative angiosome assessment

Low flap complication rates and excellent aesthetic outcomes are now commonplace in breast reconstruction. As a result, attention is now being focussed on minimising donor site morbidity. Despite its potential donor site advantages, the superficial inferior epigastric artery (SIEA) flap is often discounted, given concerns about the high flap failure rates. In this study, we present our experience of using the SIEA flap in breast reconstruction and provide an algorithm based on pre-operative computed tomography angiography (CTA) to aid pre-operative planning. A retrospective analysis of SIEA flap breast reconstruction cases performed at our unit between 2009 and 2016 was performed and outcomes were assessed. In addition, the patients' pre-operative CTA images were assessed and compared to those of a matched group of patients who underwent deep inferior epigastric artery perforator (DIEP) flap breast reconstruction. Twenty-six patients who underwent SIEA flap breast reconstruction were eligible for inclusion. No flaps were lost. Donor site seroma rate was 20%. The largest SIEA diameter in those who underwent an SIEA flap was significantly larger (p=0.0001) than in those who underwent DIEP flap breast reconstruction. Significantly more number of patients who underwent SIEA flap breast reconstruction had a SIEA diameter greater than or equal to that of the largest DIEP flap perforator (p=0.0001) in the group where a DIEP flap was used for breast reconstruction. High success rates can be achieved with abdominal flaps based on the superficial vascular system and careful pre- and perioperative assessment of patients.

The Influence of a Pfannenstiel Scar on Venous Anatomy of the Lower Abdominal Wall and Implications for Deep Inferior Epigastric Artery Perforator Flap Breast Reconstruction.

A Pfannenstiel incision involves the obstruction of superficial venous pathways and functional diversion of flow through alternative pathways and adjacent vessels. This study investigated the effect of a prior Pfannenstiel incision on venous anatomy of the lower abdominal wall; specifically, the superficial inferior epigastric vein (SIEV), using computed tomographic angiography. A case-control study was performed of 50 patients with Pfannenstiel scars and 50 age-matched, body mass index-matched control patients without Pfannenstiel scars. The authors compared the number of direct/indirect and total communications between the SIEV and deep inferior epigastric artery perforator (DIEP) venae comitantes, midline crossover, and other SIEV-related anatomical changes by using computed tomographic angiography. Flap-related clinical outcomes and donor-site-related complications were also assessed. The median number of direct and total communications between the SIEV and DIEP venae comitantes in the study group was greater than in the control group. The percentage of SIEVs having more than two branching patterns per hemiabdomen was significantly higher in the study group than in the control group. The study group also showed a significantly lower rate of fat necrosis compared with the control group (p = 0.03). The rate of donor-site seroma was significantly higher in the study group. This study suggests that the presence of a Pfannenstiel scar may promote the development of direct and total communications between the SIEV and DIEP venae comitantes and branching within the SIEV in the lower abdominal wall, which may facilitate venous drainage of adipose tissue in DIEP flap breast reconstruction. Risk, II.

Abstract: 8.50 Displaying Inguinal Lymph Nodes Before Transplantation In A Deep Inferior Epigastric Perforator Flap Breast Reconstruction Using An Innovative Projection Method

INTRODUCTION: Lymphedema of the arm is a common postoperative complication as a result of breast cancer surgery. One of the surgical treatments comprises modification of a deep inferior epigastric perforator (DIEP) flap breast reconstruction to facilitate additional lymph node transplantation from the inguinal area. Using computed tomography angiography (CTA), the distribution of these lymph nodes can be assessed. A virtual planning based on this CTA created for the DIEP flap is presented, with the inguinal lymph nodes included, followed by preoperatively projecting this information on the patients’ abdomen. MATERIALS AND METHODS: A total of ten patients underwent the standard imaging protocol: A preoperative CTA to assess the vascular anatomy of the lower abdomen. A three-dimensional (3D) model of the blood vessels was produced, and the inguinal lymph nodes in this reconstruction were included. Preoperative projection of the 3D model onto the patients’ abdomen and inguinal area was performed, followed by tracing of this image. Intra-operatively found lymph nodes were identified by touch and compared with the markings on the skin. RESULTS: In all ten patients the preoperatively indicated lymph nodes were found within a one-centimeter radius. According to expert opinion, these lymph nodes were more easily identified in the subcutaneous fat than without using the projection method. CONCLUSIONS: Virtual planning of lymph node transplantations in a deep inferior epigastric artery perforator flap breast reconstruction seems feasible and can be performed quickly. This additional visual support aids the surgeon in locating the lymph nodes in the inguinal area. 9.00- 9.30 Keynote Lecture 3 THE SCIENCE OF TISSUE EXPANSION Alex MARGULIS Hadassah, Israel 9.50–11.10 SESSION 7 – ANGIOGENESIS, WOUND HEALING & BURNS Moderators Aernout LUTTUN Laurence BOON

90. Neurotisation in deep inferior epigastric artery perforator (DIEP) flap breast reconstructions: Our technique and results

90. Neurotisation in deep inferior epigastric artery perforator (DIEP) flap breast reconstructions: Our technique and results

84. Complications in primary versus secondary deep inferior epigastric artery perforator (DIEP) flap breast reconstructions: A multicentre study

84. Complications in primary versus secondary deep inferior epigastric artery perforator (DIEP) flap breast reconstructions: A multicentre study

Contralateral breast symmetrisation in unilateral DIEP flap breast reconstruction

Women undergoing unilateral deep inferior epigastric artery perforator (DIEP) flap breast reconstruction may be offered a contralateral symmetrisation either at the time of reconstruction (simultaneous/immediate) or at a later stage (delayed). Simultaneous contralateral breast symmetrisation may be more beneficial to patients and healthcare institutions by avoiding staged surgery, although there is limited evidence on which to base practice. This deficit formed the rationale for our study. The primary outcome was the overall rate of revision surgery. Over a 6-year period, this prospective cohort study recorded the demographics, cancer treatments and operative outcomes of all consecutive unilateral DIEP flap breast reconstructions with or without contralateral symmetrising surgery. Patients were categorised into three groups: (1) simultaneous symmetrisation, 2) delayed symmetrisation and (3) no symmetrisation for comparative analysis. During the study period, 371 women underwent unilateral DIEP flap breast reconstruction 194 (52.3%) were not symmetrised, 155 (41.8%) were simultaneously symmetrised and 22 (5.9%) underwent delayed symmetrisation. Simultaneous symmetrisation of the contralateral breast and unilateral DIEP flap breast reconstruction increased the mean total operative time by 28min. There were no differences in the rates of peri-operative complications. There were significantly higher rates of all-cause revision surgery (OR 3.97 [1.58, 9.94], p=0.003) in women undergoing delayed symmetrisation, because of higher rates of revision lipomodelling, scar revision and revision contralateral symmetrisation. Simultaneous contralateral breast symmetrisation was associated with a lower risk of all-cause revision surgery. It is safe, beneficial and likely to be more cost-effective for women undergoing unilateral free DIEP flap breast reconstruction.

Complications in unilateral versus bilateral deep inferior epigastric artery perforator flap breast reconstructions: A multicentre study

The deep inferior epigastric artery perforator (DIEP) flap is the first choice for autologous breast reconstruction. The aim of this retrospective cohort study was to analyse the recipient- and donor-site complications and compare them between unilateral and bilateral DIEP flap breast reconstructions. Between January 2010 and December 2014, 530 DIEP flap reconstructions were performed in 426 consecutive patients in three Dutch hospitals. Major and minor complications were categorised into recipient- and donor-site complications. Post-operative flap re-explorations were recorded. Of the total 530 DIEP flap reconstructions performed (322 unilateral, 104 bilateral), recipient-site complications were major in 9.8% and minor in 20.2%. The patients developed fat necrosis (unilateral 14.0% vs. bilateral 7.7%; OR 1.950; 95% CI 1.071-3.550; p=0.027) and infection (unilateral 5.6% vs. bilateral 1.9%; OR 3.020; 95% CI 1.007-9.052; p=0.039) at the recipient site significantly more frequently in the unilateral DIEP flap reconstructions. The donor-site complications were major in 0.9% and minor in 19.5% of the cases. Body mass index (BMI) was significantly associated with complications (donor site: OR 1.137; 95% CI 1.075-1.201; p<0.001, recipient site: OR 1.073; 95% CI 1.009-1.142; p=0.026). Flap re-explorations were performed in 5.7% (n=30) of the cases. Total flap loss occurred in 3.0% (n=16) of the cases. Bilateral DIEP flap breast reconstructions can be performed with the same percentage of complications and re-explorations as unilateral reconstructions and even result in less fat necrosis and infection at the recipient site. Higher BMIs are significantly associated with recipient- and donor-site complications.

Deep Inferior Epigastric Artery Perforator Flap Breast Reconstruction in Patients With Previous Bariatric Surgery: Is It Safe and Feasible?

Obesity is widely recognized as a major health concern and a leading cause of preventable death. The correlation between obesity and breast cancer has been thoroughly described by several authors. Bariatric surgery is often associated with redundant abdominal tissue, often leading patients to consider body-contouring procedures. Autologous tissue breast reconstruction using the deep inferior epigastric artery perforator (DIEP) flap has advantages because it is tissue that is normally discarded during postbariatric body contouring. We conducted a retrospective chart review of 18 DIEP flaps performed by the senior author in 9 patients for breast reconstruction between February 2008 and May 2013. All patients underwent mastectomies. All patients underwent bariatric surgery preceding breast reconstruction. Breast reconstruction was performed immediately in 13 cases and delayed in 5 cases. Mean age of the study population was 44.6 years (range, 41-57 years). The mean maximum body mass index of the patients was 44 (range, 37.6-52.1), and the mean current body mass index at the time of the reconstruction was 30.7 (range, 24.3-38.1). No intraoperative complications were reported. No fascia or muscle was taken during flap dissection. Mean operative time was 632 minutes (range, from 480 to 750 minutes). Average hospital stay was 4 days. No partial or total flap loss was reported. There were no postoperative hernias or bulges at the abdominal donor site. This series represents the largest group of patients undergoing DIEP flap breast reconstruction after bariatric surgery. In the hands of experienced microsurgeons, breast reconstruction with the DIEP flap in postbariatric patients represents a low-risk option with high satisfaction.

Displaying inguinal lymph nodes before transplantation in a deep inferior epigastric perforator flap breast reconstruction using an innovative projection method

Lymphedema of the arm is a common postoperative complication as a result of breast cancer surgery. One of the surgical treatments comprises modification of a deep inferior epigastric perforator (DIEP) flap breast reconstruction to facilitate additional lymph node transplantation from the inguinal area. Using computed tomography angiography (CTA), the distribution of these lymph nodes can be assessed. A virtual planning based on this CTA created for the DIEP flap is presented, with the inguinal lymph nodes included, followed by preoperatively projecting this information on the patient's abdomen. A total of 10 patients underwent the standard imaging protocol: A preoperative CTA to assess the vascular anatomy of the lower abdomen. A three-dimensional (3D) model of the blood vessels was produced, and the inguinal lymph nodes in this reconstruction were included. Preoperative projection of the 3D model onto the patients' abdomen and inguinal area was performed, followed by tracing of this image. Intraoperatively found lymph nodes were identified by touch and compared with the markings on the skin. In all 10 patients, all lymph nodes located preoperatively were found intraoperatively within a 1-cm radius of the marking on the skin; and these were more easily located by two operating surgeons. Virtual planning of lymph node transplantations in a deep inferior epigastric artery perforator flap breast reconstruction seems feasible and can be performed quickly. This additional visual support aids the surgeon in locating the lymph nodes in the inguinal area.

Deep Inferior Epigastric Artery Perforator Flap Breast Reconstruction without Microsurgery Fellowship Training.

Background:Deep inferior epigastric artery perforator (DIEP) flap breast reconstruction requires complex microsurgical skills. Herein, we examine whether DIEP flap breast reconstruction can be performed safely without microsurgical fellowship training.Methods:A total of 28 patients and 34 DIEP flaps were included in the study. We reviewed the medical records of patients for donor site and flap-related complications and analyzed the correlation between the complications and preoperative risk factors. We also performed a literature review to compare complication rates in our series with the literature.Results:We observed total flap necrosis in 1 patient (2.9%), partial flap necrosis in 5 patients (14.7%), infection in 1 patient (2.9%), hematoma/seroma in 3 patients (8.8%), donor site complications in 5 patients (18.5%), venous occlusion in 4 patients (11.7%), and arterial occlusion in 1 patient (2.9%). We did not observe any correlation between complications and preoperative risk factors. Literature review yielded 18 papers that met our inclusion criteria. Partial flap necrosis rate was significantly higher in our series compared with literature (14.7% vs 1.6%, P = 0.003). Venous complication rate was marginally higher in our series compared with literature (11.7% vs 3.3%, P = 0.057). However, total flap loss rate in our series was comparable with the literature (2.9% vs 2.2%, P = 0.759).Conclusion:With proper training during plastic surgery residency, DIEP flap can be performed with acceptable morbidity.

Deep Inferior Epigastric Artery Perforator Flap Donor-Site Closure with Cannula-Assisted, Limited Undermining, and Progressive High-Tension Sutures versus Standard Abdominoplasty

In deep inferior epigastric artery perforator (DIEP) flap breast reconstruction, abdominal donor-site cosmetic and sensibility outcomes and the closure technique have drawn little attention in the literature, with many surgeons still following the principles of standard abdominoplasty. In this article, the authors report their experience with the cannula-assisted, limited undermining, and progressive high-tension suture ("CALP") technique of DIEP donor-site closure compared with standard abdominoplasty. Between December of 2008 and January of 2013, 137 consecutive women underwent DIEP flap breast reconstruction. Of these, 82 patients (between December of 2008 and November of 2011) underwent DIEP flap donor-site closure by means of standard abdominoplasty (control group) and 55 patients (from December of 2011 to January of 2013) by means of cannula-assisted, limited undermining, and progressive high-tension suture (study group). The abdominal drainage daily output, donor-site complications, abdominal skin sensitivity at 1-year follow-up, cosmetic outcomes, and patient satisfaction were recorded and analyzed statistically. Daily drainage output was significantly lower in the study group. Donor-site complications were significantly higher in the control group (37.8 percent versus 9 percent). Seroma and wound healing problems were experienced in the control group. Abdominal skin sensibility was better preserved in the study group. Overall, abdominal wall aesthetic outcomes were similar in both groups, except for scar quality (better in the study group). According to the authors' experience, cannula-assisted, limited undermining, and progressive high-tension suture should be always preferred to standard abdominoplasty for DIEP donor-site closure to reduce the complication rate to improve abdominal skin sensitivity and scar quality. Therapeutic, II.

Reply to: ‘The increased risk of adverse outcomes in bilateral deep inferior epigastric artery perforator flap breast reconstruction compared to unilateral reconstruction’

1. The authors eloquently established their reason for expressing the prevalence of adverse events per patient rather than per flap. This is important if our goal is to have informed pre-operative discussions with our patients. Simply put, flaps do not sue; patients do. For that reason, the more information that can be conveyed to the patient pre-operatively, the better. 2. The authors honestly admitted that their findings could be explained by selection bias and more importantly that their findings might be statistically significant, but clinically unimportant.

Effect of Acetylsalicylic Acid on Microvascular Thrombosis in Autologous Breast Reconstruction

Although advances in microsurgery have increased success rates of autologous breast reconstruction, microvascular thrombosis still remains a major concern as a cause of flap failure. At present, no evidence-based guidelines on pharmacological prevention of microvascular thrombosis exist. This study investigates the effect of acetylsalicylic acid on the incidence of microvascular complications in patients undergoing autologous breast reconstruction. Patients undergoing deep inferior epigastric artery perforator or free transverse rectus abdominis myocutaneous flap breast reconstruction at two academic centers in the Netherlands between 2005 and 2011 were included. Patients at one center received once daily 0.6 mL of nadroparine and 40 mg acetylsalicylic acid, while patients at the other center received 0.6 mL nadroparine only. A total of 430 consecutive patients underwent 592 breast reconstructions. No statistically significant differences were found between the two groups in the incidence of flap failure (2.8 and 2.5%), microvascular thromboembolic complications (2.6 and 3.8%), venous congestion (3.4 and 2.8%), or overall complications (28.0 and 32.3%). Hematoma tended to occur more often in the group receiving acetylsalicylic acid (9.2 and 4.7%).It was found that no protective effect of acetylsalicylic acid on microvascular complications was present. Given its known risks and the somewhat increased occurrence of hematoma in the present study, we stopped to routinely administer acetylsalicylic acid after autologous breast reconstruction.

A Method of Preoperatively Assessing the Volume of Abdominal Tissue Available for an Autologous Breast Reconstruction

Sir:FigureWe have developed an office-based method of assessing the volume of abdominal tissue available for breast reconstruction that has proved to be accurate, reproducible, and noninvasive, yet relatively simple, quick, cost-effective, and of no inconvenience to our patients. We prospectively evaluated 30 sequential immediate deep inferior epigastric artery perforator flap breast reconstructions (25 unilateral and five bilateral). For assessment of breast weight, we used Bostwick's graph1 to preoperatively calculate the patient's breast weight based on their cup size and chest wall circumference. We validated this by weighing the mastectomy specimen (actual breast weight). For assessment of flap volume, standard flap markings were used and the elliptical flap was considered as two identical triangles. The area of each triangle was calculated using the standard formula: area of triangle = height × width × ½. The following measurements were obtained: width was measured by dropping a vertical line from the umbilicus to the suprapubic region, and height was measured from this line to the apex of the triangle (Fig. 1).Fig. 1: The marked elliptical flap area is considered as two identical triangles, with each triangle's area being calculated using the formula width (W) × height (H) × ½.To calculate the volume of the flap, the thickness of the abdominal skin and fat were measured using a metal calliper while the abdominal panniculus was grasped by the assistant (Fig. 2). Three measurements were taken and the average of these was used. This measurement was divided by 2 (as the abdominal wall is folded onto itself during the measurement) and multiplied by the area of the flap. Therefore, the final formula for calculation of the flap volume is as follows: calculated flap volume = (height × width × ½) × 2 × (flap thickness × ½).Fig. 2: The thickness of the flap is measured using a metal calliper while the abdominal panniculus is grasped by the assistant.These calculations were validated by measuring the thickness and weight of the flap (actual flap weight) once harvested. The average calculated breast weight was 585 g (range, 345 to 1560 g) and the average actual breast weight was 505 g (range, 295 to 1510 g), giving an average percentage error of 16 percent. The average calculated flap volume was 1306.6 ml (range, 468 to 2758.5 ml) and the average actual flap volume was 1371 g (range, 480 to 2880 g), giving an average percentage error of 4.74 percent. The average flap thickness as measured with calipers was 3.15 cm (range, 2 to 4.7 cm) and the average flap thickness measured perioperatively was 3.85 cm (range, 2.5 to 5.4 cm). We have developed a reliable method for the preoperative assessment of flap volume using simple mathematical principles that has proved to be an invaluable tool during our first consultation, both in managing patient expectations and in constructing an operative plan. It has been particularly useful (1) to confidently inform patients of the size of the reconstructed breast; (2) in bilateral reconstructions, to assess whether a sufficient volume of flap is available; and (3) to determine whether a contralateral reduction will be required. In these highly litigious times, such a comprehensive consultation is vital for the purposes of both informed consent and ensuring that the patient's expectations mirror our own. In addition, perioperative decisions can be facilitated.1 If a hemiflap provides sufficient volume, the superficial inferior epigastric artery pedicle can be used.2,3 In the case of large-volume (>1000 ml) breast reconstructions, the consideration of whether to raise a free transverse rectus abdominis musculocutaneous or a deep inferior epigastric artery perforator flap and in the latter how many perforators are required can be facilitated.4 We have described a validated method of calculating the abdominal flap volume available to patients undergoing autologous breast reconstruction. This technique is simple, consistently reliable, and cost effective, and has allowed us to refine our practice. Pari-Naz Mohanna, F.R.C.S.(Plast.) Jian Farhadi, F.M.H. GKT Cancer Reconstruction Service, St. Thomas' Hospital, London, United Kingdom DISCLOSURE The authors have no financial interest to declare in relation to the content of this article.

Bilateral autologous breast reconstruction with deep inferior epigastric artery perforator flaps: Review of a single surgeon's early experience

The purpose of this study is to describe the early experience of a single surgeon just out of training, including preoperative conditioning, surgical approach, and outcomes in bilateral deep inferior epigastric artery perforator (DIEP) flap breast reconstruction patients. We retrospectively reviewed 54 consecutive patients who underwent 108 DIEP flap breast reconstructions performed by a single surgeon over an initial 2.5-year period. There was 100% overall flap survival. The unplanned reoperation rate was 7.6% (n = 4). Minor complications including nonoperative infection, minor wound dehiscence, and donor site seroma occurred in 26% of patients (n = 14). Significant late complications were abdominal wall bulge (n = 1) and fat necrosis < 10% of volume (n = 1). Tissue expander explantation due to infection occurred in 25% of attempted staged patients (two of eight); this did not seem to compromise their oncologic treatment or final reconstruction outcome. This study demonstrates the efficacy of the DIEP flap for bilateral autologous breast reconstruction in the immediate, staged, and delayed settings.