Inferior Epigastric Artery Perforator Flap Research Articles

Linked Flaps of the Thoracodorsal Vascular Tree for Correcting Extensive Post-Burn Deformities and Achieving Optimal Reconstruction Outcomes.

Autologous skin grafting has been the popular method for reconstructing post-burn defects. However, this technique has limitations such as high contracture rates and inadequate volume coverage. This report aims to propose the principles and advantages of utilizing microsurgically linked perforator flaps for the reconstruction of extensive burn defects and associated post-burn scar contracture in the lower and upper extremities and trunk. Patients who underwent free tissue transfer for primary and secondary burn wound reconstruction at a single institution between 2016 and 2023 were included in the study. Patients received thoracodorsal vascular tree-linked flaps for the correction of post-burn deformities. Postoperative results were evaluated, including flap survival, complications, and the DASH self-report questionnaire for upper extremity reconstruction. Among the 20 patients, 12 required primary reconstruction, while 8 underwent secondary reconstruction using anastomotic chimeric free tissue transfer. The majority of burn injuries resulted from thermal contact (n = 8), followed by flames (n = 5), scalds (n = 4), electrical contact (n = 2), and friction (n = 1). The most frequently utilized combinations were the thoracodorsal artery perforator (TDAp) and anterolateral thigh (ALT) flap (11 cases). Additionally, four cases involved the pedicled TDAp flap in conjunction with the deep inferior epigastric artery perforator (DIEP) flap. The average DASH score for upper extremity burn patients was 10.58. Three-dimensional tissue coverage achieved through the linkage of two or even three independent free flaps is increasingly utilized in post-burn reconstruction. This approach offers multiple advantages and represents a viable option for burn reconstruction.

Breast reconstruction using the superficial circumflex iliac artery superficial branch perforator (SCISP) flap.

The deep inferior epigastric perforator (DIEP) flap is the gold standard for autologous breast reconstruction. One downside is its risk of postsurgical herniation and bulging due to the opening of the rectus fascia and intramuscular dissection of the rectus abdominis muscle. Additionally this part of the surgery is very time consuming. While the superficial inferior epigastric artery perforator (SIEA) flap has been thoroughly described for total autologous breast reconstruction, the use of the superficial circumflex iliac artery perforator flap in this field is limited. This series introduces the use of an extended superficial circumflex iliac artery (SCIA) perforator flap nourished solely by perforators of the superficial branch of the SCIA- artery for total autologous breast reconstruction.Superficial preparation over the abdominal wall was performed without incising the rectus fascia, dissecting the superficial branch of the SCIA and its accompanying veins and the superficial inferior epigastric vein for additional venous drainage.Four patients underwent successful autologous breast reconstruction with this extended SCIP (superficial circumflex iliac artery perforator)-flap-variation. The term superficial circumflex iliac artery superficial branch perforator (SCISP) flap was introduced to standardize the surgical technique for using only perforators of the superficial branch of the SCIA as free flaps.The SCISP flap is safe and viable for total autologous breast reconstruction, particularly for women with small to medium sized breasts and with superficial dominance of the abdominal vascular system.

Incidence of and risk factors for post-operative venous thromboembolism after free flap breast reconstruction in a London teaching hospital: A retrospective cohort study

The objective of this study was to determine the incidence of venous thromboembolism (VTE) following autologous breast reconstruction, assess risk factors that may predict incidence and assess the accuracy of the Caprini risk assessment model. VTE is a rare, but potentially lethal complication of autologous breast reconstruction. An accurate preoperative risk-stratification strategy is essential to improve patient outcomes by determining the patients who would benefit from extended thromboprophylaxis after surgery. Patients who underwent autologous free flap breast reconstruction at a London teaching hospital from 2019-2021 were included. Risk factors for VTE were analysed. VTE incidence was assessed, and the risk factors were identified using multivariate analysis. Overall, 368 patients were included in the study. Among them, 10 (2.72%) had a confirmed diagnosis of post-operative VTE, at an average of 23 days after surgery (range 3-64 days). All VTEs occurred in deep, inferior epigastric artery perforator flap patients with a history of breast cancer. Multivariate regression analysis revealed a statistically significant correlation between the incidence of VTE and Caprini score (p=0.030) and length of hospital stay (p=0.007). Tamoxifen use was individually significant for VTE (p=0.043) but non-significant (p=0.106) when confounded for length of hospital stay (LOS) and Caprini score. Current VTE risk assessment tools do not accurately identify patients who are at risk of developing VTE following free flap breast reconstruction. The Caprini risk assessment model and LOS may be useful in predicting post-operative VTE in this cohort. These patients may benefit from extended chemoprophylaxis. Larger prospective studies are required to optimise risk prediction models in this cohort.

Hug Flap and Hamdi Hammock: Two Innovative Techniques for Enhancing Aesthetic Outcomes in Deep Inferior Epigastric Artery Perforator Breast Reconstruction.

Achieving optimal aesthetic outcomes in deep inferior epigastric artery perforator (DIEP) flap breast reconstruction remains a challenge, often necessitating additional procedures for refinement. This study presents two innovative techniques (the hug flap and Hamdi hammock) aimed at enhancing breast projection and inframammary fold (IMF) definition in DIEP flap reconstruction. The hug flap technique uses de-epithelialized caudal mastectomy skin to augment breast projection, whereas the Hamdi hammock uses a percutaneous purse-string suture to define the IMF. A retrospective review of 782 patients who underwent DIEP flap breast reconstruction between 2007 and 2023 was conducted. The hug flap group required significantly less additional fat grafting compared to other techniques (11% versus 27% and 22%). No total flap losses occurred in the hug flap group, and fat necrosis rates were low. The Hamdi hammock was used in 405 patients with a mean of two lipofilling sessions. Complications were minor and no stitches required removal. The hug flap and Hamdi hammock techniques offer effective and safe methods for enhancing breast projection and IMF definition in DIEP flap reconstruction. These techniques may reduce the need for additional procedures and improve aesthetic outcomes.

Gender-affirming DIEP Flap Breast Augmentation.

Implant-based techniques have been the mainstay of gender-affirming breast augmentation (GABA). Here we describe a novel autologous technique for GABA. We provide a single-patient case report of gender-affirming deep inferior epigastric artery perforator (DIEP) flap breast augmentation. World Professional Association for Transgender Health guidelines were followed according to Standards of Care, version 8. Prepectoral tissue expanders were placed at the time of the patient's facial feminization surgery. DIEP flaps were then used for bilateral breast augmentation. Planned revisions were made about 5 months later. Breast augmentation was performed successfully with DIEP flaps, and the patient was satisfied with her outcome. No complications occurred. Anatomic differences to cisgender women were noted, including relatively thick musculature of the abdominal wall and chest as well as tight anterior abdominal fascial closure. Advantages compared with implant-based GABA were also noted, including feminization of the abdomen and avoidance of potential implant related complications. We report a novel approach to GABA. Our approach borrows well-established techniques with demonstrated efficacy and high satisfaction in postmastectomy breast reconstruction and even cosmetic purposes. However, sex- and hormone-influenced anatomic differences required some modifications compared with postmastectomy DIEP flap reconstruction.

Validating the porcine model for microsurgical perforator training: Can surgeons trained on pig perforator dissection successfully perform human DIEP flap procedures? A pilot study

Autologous breast reconstruction, especially using the deep inferior epigastric artery perforator (DIEP) flap, is increasingly seen as a reliable, safe, and long-term alternative to implant-based reconstruction. Despite the recognized advantages of the DIEP flap for breast reconstruction, successful realization demands excellent anatomical knowledge, a thorough understanding of autologous breast reconstruction concepts and advanced microsurgical skills. Given that the porcine model is widely employed in microsurgical training, our study aims to assess this model using validated outcomes, with the objective of evaluating the enhancement in a surgeon's learning curve following training with this model. Forty DIEP flaps were harvested on 20 swines by a single surgeon in "Pius Branzeu Center" (Timisoara, RO) and "Drazan Institute" (University of veterinary of Brno, CZ) laboratories for microsurgical training in 6months (January 2015-June 2015). Then we analyzed data from 40 DIEP flaps harvested by the same surgeon on first 20 consecutive patients undergoing DIEP flap breast reconstruction. Perforator dissection time, surgeon-determined dissection difficulty score (DDS) and venous congestion rate were collected for each flap in porcine model and in patients, then compared and analyzed. The mean of DDS score analysis in first and second swines group dissection resulted as statistically significant (P-value 0.0001), while it was not statistically significant between those analyzed in the second group of swines dissected and patients (P-value 0.8037). Reduction in perforator dissection time between the two swines' groups and in venous congestion rates from the first swines groups to the second to the human group resulted statistically significant too (P-value respectively 0.0001 and 0.0079). The porcine model has been used for a long time together with other animal models for microsurgical training. Our study confirms and objective by validated scores that it is a valid and reliable model, comparable to the human one and which mimics the dissection of human perforating vessels.

Flaps of the abdominal wall

Objective: The deep inferior epigastric artery perforator (DIEP) and transverse-vertical rectus abdominis myocutaneous (TRAM, VRAM) flaps are derived from the anterior abdominal wall and can be free or pedicled. This study aimed to analyze the differences in postoperative complication rates among various types of abdominal flaps and to assess the impact of chemotherapy (CT) and radiotherapy (RT) on surgical outcomes. Materials and Methods: A retrospective study was conducted, analyzing abdominal flap operations performed between 2016 and 2023. Data on demographics, defect location, mesh use, and postoperative chemo-radiotherapy were collected. Quantitative variables were evaluated as means, minimum-maximum values, and categorical variables were assessed as percentages. Results: A total of 37 patients underwent 38 operations. Of these, nine patients had pedicled TRAM flaps, 16 had free-TRAM flaps, 6 had free DIEP flaps, and 6 had VRAM flaps. The defect locations were predominantly for breast reconstruction (81.08%), followed by head and neck (8.1%), extremity (8.1%), and thoracic wall (2.7%). The overall donor site complication rate was 5.4%, and the flap site complication rate was 13.51%. The lowest donor site complications were observed in the free-TRAM and VRAM groups (0%), while the highest were in the DIEP group (16.66%). The lowest flap site complication rate was 0% in the free-TRAM group, and the highest was 33.33% in the VRAM group. Donor site complication rates were similar between the mesh-used (5.88%) and non-mesh-used (5%) groups. All donor site complications occurred in patients who received postoperative CT and RT. Conclusion: Abdominal flaps were primarily utilized for breast reconstruction. The free-TRAM group exhibited the lowest donor and flap site complication rates, while the DIEP group had the highest donor site complication rates. Mesh use did not affect donor site complication rates. Postoperative administration of CT and RT was associated with increased donor site complications.

Ultrasound-guided preoperative skin-marking for deep inferior epigastric perforator flap surgery.

Deep inferior epigastric artery perforator (DIEP) flaps remain the gold standard of autologous breast reconstruction. However, the surgical technique entails a steeper learning curve and typically requires a higher mean surgical time, in part due to the time and effort involved in physical localization of appropriate perforators at the time of surgery. This is typically performed using Doppler ultrasound, and is a potentially challenging and time-consuming task in the hands of an untrained operator. In order to mitigate these challenges, ease time pressures, promote efficient utilization of our operating theatres and improve surgical outcomes, our institution routinely performs skin-marking in advance at the Breast Radiology department. In this article, we describe our technique and experience with the procedure.

Noninvasive visualization of the midline-crossing arterial variation in the deep inferior epigastric artery perforator flap using photoacoustic tomography for application in patients with abdominal scars

BackgroundThe importance of the subcutaneous arterial network crossing the midline in transverse abdominal flaps has been reported. Photoacoustic tomography can be used to noninvasively visualize subcutaneous vascular networks. We applied this novel technology preoperatively in patients undergoing breast reconstruction to detect individual variations in the midline-crossing arteries. MethodsSix patients scheduled to undergo breast reconstruction using free deep inferior epigastric artery perforator flaps were examined. Each scan of the 12×8-cm region took approximately 8min. The accuracy of the tentative arteries evaluation defined by photoacoustic tomography was compared with the arterial phase detected by intraoperative indocyanine green angiography. The number of perforator vessels used for the flap, surgical time for flap elevation, and perfusion area ratio were compared with those of the control group. ResultsThe average match rate between tentative arteries prediction by photoacoustic tomography and arterial-phase assessment by intraoperative angiography in 5 patients was 79.8%. Each midline crossing artery showed individual variations. The photoacoustic tomography group (PAT-1 to 5) showed 1.8 perforators per flap, 163minutes for flap elevation, and 93% perfusion area, with no significant differences from the control group (N=5). A 63-year-old woman (PAT-6) with abdominal scars, including a midline abdominal incision, showed a preserved midline crossing artery. The planned single perforator deep inferior epigastric perforator flap was successfully applied to the contralateral perfusion area. ConclusionsPhotoacoustic tomography noninvasively visualizes the subcutaneous midline-crossing arterial networks. Understanding individual vascular variations can support preoperative planning and surgical indication of abdominal flaps, especially in patients with postsurgical scars.

Fat Necrosis in Single Perforator Deep Inferior Epigastric Artery and Superficial Epigastric Artery Perforator Free Flaps: A Prospective Randomized Study.

The deep inferior epigastric perforator (DIEP) flap is the standard of care in autologous breast reconstruction. The superficial inferior epigastric artery perforator flap (SIEA) is an alternative reconstructive option, with the compromise of less donor-site morbidity but variable perfusion to subscarpal fat zones. Fat necrosis is a known complication from marginal perfusion variability. Volumetric analysis of fat necrosis has not been performed between the two reconstructive options, nor has the amount of flap necrosis following radiation. Our objective was to compare rates and volume of fat necrosis between single-perforator DIEP and SIEA flap techniques. A single-center, blinded, prospective cohort study of patients randomized between SIEA and DIEP breast reconstruction was conducted over 2 years (June 2011-July 2013). Inclusion criteria were women undergoing immediate reconstruction following mastectomy. Randomization protocols were strictly followed. Fat necrosis volumetric analysis was determined by an ultrasound-trained attending surgeon at 12 months postoperatively. Patient demographics and adjuvant/neoadjuvant cancer treatment were analyzed. Statistical analyses included Mann-Whitney U tests, chi square, and/or Fisher exact tests. P values of 0.05 or less were considered significant. Fat necrosis was detected in 11 of 46 flaps (23.9%), with a median area of 17.9 cm2. There was no significant difference in prevalence of fat necrosis between the two flap types (P = 0.19). Postoperative radiation did not increase the prevalence (P = 0.30) or extent (P = 0.92) of fat necrosis. Single-perforator DIEP and SIEA flaps have comparable rates of fat necrosis. Postoperative radiation did not result in increased prevalence or extent of fat necrosis.

Strategically shifting paradigms: the new era of DIEP flaps with minimally invasive mastectomy: a retrospective cross-sectional study

BackgroundThe free deep inferior epigastric artery perforator (DIEP) flap is the gold standard in autologous breast reconstruction. Asian patients often present with a smaller body mass index with relatively insufficient tissue. To restore appropriate symmetry, a larger flap inset ratio must be transferred. Supercharging of the second vein or inclusion of bilateral pedicle is commonly required. Current paradigm shifts in mastectomy has also resulted in more minimally invasive surgeries (MIS) espousing smaller lateral incisions, leading to a significant change in available recipient vessels. This study aimed to demonstrate our experience in changing strategies of DIEP flaps following the evolution of mastectomy techniques.MethodsBetween October 2008 and March 2022, retrospective data was gathered for 278 patients who underwent breast reconstruction surgery utilizing DIEP flaps by a single plastic surgeon. These patients were divided into two distinct groups based on their operation dates, with November 2018 marking a pivotal moment when the first MIS, including endoscopic-assisted and robot-assisted mastectomy, was introduced.ResultsA total of 278 patients were included. Bipedicle vessel utilization for flap supercharge saw a significant increase (15.9% vs. 7%, p < 0.001), while the use of the superior inferior epigastric vein (SIEV) decreased (5.1% vs. 17.1%, p = 0.01). Preceding MIS, SIEV was the primary choice for flap supercharge (96.0%, p < 0.001), whereas post-introduction, the contralateral DIEP pedicle gained prominence (75.9%, p < 0.001). There was also an increased utilization of thoracodorsal artery and lateral thoracic artery following MIS.ConclusionThese findings underscore the profound impact of MIS on the strategic choices made in DIEP flap-based breast reconstruction.Trial registrationThis study is retrospectively registered on ClinicalTrials.gov (NCT06321549).

Multiple intramuscular ropivacaine injections to donor sites reduces pain in deep inferior epigastric artery perforator flap breast reconstruction

Local anesthetic infiltration at the surgical site has been studied in various surgical disciplines; however, its impact on deep inferior epigastric artery perforator (DIEP) flap breast reconstruction has not been previously assessed. This study aimed to evaluate the effects of multiple intramuscular ropivacaine injections on donor site pain during DIEP flap breast reconstruction. The study included 65 patients who received local ropivacaine injections during DIEP reconstructions between March 2022 and February 2023, compared to 55 patients who underwent surgeries without ropivacaine from October 2018 to July 2020. A total of 20 cc of 0.75% ropivacaine solution was evenly administered at 20 sites along the abdominal wall muscles. The effect of intramuscular ropivacaine injection on postoperative visual analog scale (VAS) was evaluated using linear mixed-effect model. Opioid consumption and hospital days were also compared. The daily median VAS score was lower in the ropivacaine group (all p-values < 0.001). When analyzed using a linear mixed-effects model, those who received ropivacaine had significantly lower VAS scores over the first 5 days postoperatively (p-value < 0.001). The rate of VAS score decline was also faster in the ropivacaine group over the first 24h postoperative (p-value = 0.045). Although opioid consumption was comparable between the groups, those receiving ropivacaine had significantly shorter hospital stay (p-value = 0.001) and no complications related to the injections were observed. Multiple intramuscular injections of ropivacaine to the donor site may reduce postoperative pain and shorten hospital stays, without increasing opioid consumption.

Hyperbaric oxygen therapy outcomes in post-irradiated patient undergoing microvascular breast reconstruction: A preliminary retrospective comparative study

Radiotherapy is a challenge in autologous breast reconstruction because of its impact on cutaneous and vascular systems. Hyperbaric oxygen therapy (HBOT) is a recognized treatment of radiation-related complications. We aimed to assess the impact of perioperative HBOT on irradiated breast microvascular reconstructive outcomes. We reviewed the medical charts of patients who received radiotherapy and then underwent secondary free autologous breast reconstruction at our institution. Data on demographics, HBOT protocol, intervention characteristics and post-operative complications were collected. Outcomes of the irradiated patients were then compared between the HBOT and non-HBOT groups. Fourteen patients were included (11 unilateral and 2 bilateral deep inferior epigastric artery perforator flaps and 1 free transverse rectus abdominis muscle flap). Seven patients received HBOT and 7 did not. In the non-HBOT group, there were 1 Clavien-Dindo grade II, 1 Clavien-Dindo grade IIIa and 2 Clavien-Dindo grade IIIb post-operative complications. In the HBOT group, there were 3 Clavien-Dindo grade I, 1 Clavien-Dindo grade IIIa and 2 Clavien-Dindo grade IIIb post-operative complications. The mean operative time was 452.3 minutes (SD ±62.4 minutes) for unilateral cases without HBOT and 457.8 minutes (SD ±102.1 minutes) with HBOT (p=0.913). Mean ischaemia time per flap without HBOT was 109.4 minutes (SD ±51.8 minutes) versus 80.1 minutes (SD ±37.7 minutes) in the HBOT group (p=0.249). This study provides insights into the potential of HBOT treatment in preparing patients with irradiated breast cancer for secondary autologous reconstruction.

A New Era in Perforator Flap Surgery for Breast Reconstruction: A Comparative Study of Robotic versus Standard Harvest of Bilateral Deep Inferior Epigastric Artery Perforator Flaps.

Traditional deep inferior epigastric artery perforator (DIEP) flap harvest splits the anterior sheath, weakening the abdominal wall and predisposing patients to bulge or hernia. Abdominal wall morbidity may be decreased using minimally invasive techniques. We refined a transabdominal approach to the robotic harvest of bilateral DIEP flaps. A retrospective medical record study involving all patients who underwent bilateral or bipedicled robotic DIEP (rDIEP) or standard DIEP (sDIEP) flap harvest between July 2021 and September 2022. Outcomes included abdominal wall morbidity, total operative time, length of stay (LOS), and complications. Forty-seven patients were included (48 sDIEP flaps, 46 rDIEP flaps) with no significant difference in patient characteristics. Fascial incision length in the rDIEP group was shorter (4.1 vs. 11.7 cm, p < 0.001). Mesh reinforcement of the abdominal wall was used in 13/24 sDIEP and none in rDIEP patients (p < 0.001). Operative time was longer in the rDIEP cohort (739 vs. 630 minutes, p = 0.013), although subanalysis showed no difference in the second half of the cohort. The average robotic dissection time was 135 minutes, which decreased significantly with the surgeon's experience. There were no intraoperative complications from using the robot. LOS was shorter with rDIEP but not statistically significant (3.9 vs. 4.3 days, p = 0.157). This study represents the most extensive cohort analysis of bilateral rDIEP flap harvest, offering a comprehensive comparison to traditional sDIEP. The initial results underscore the viability of robotic techniques for flap harvesting, highlighting potential advantages including reduced fascial incision length and decreased abdominal disruption. Furthermore, using robotics may obviate the necessity for fascial reinforcement with mesh.

The largest perforator of DIEP flap has a higher rate of continuity with the superficial inferior epigastric artery

In deep inferior epigastric artery (DIEA) perforator (DIEP) flap breast reconstruction, the network with the superficial inferior epigastric artery (SIEA) is key to achieving stable subcutaneous blood flow to the flap. This study investigated how the diameter and location of the DIEA perforator affect continuity with the SIEA. A retrospective analysis of 94 specimens from 47 patients who underwent DIEA perforator flap breast reconstruction was performed. Relationships between the diameter and location of the DIEA perforator and its continuity with the SIEA were examined on preoperative multi-slice computed tomography. The largest DIEA perforator on each specimen showed continuity with the SIEA in 94%, significantly more than the second (80%; p=0.027) or third largest perforator (76%; p=0.005). Medial perforators from 3cm above to 3cm below the umbilicus showed more continuity with the SIEA than lateral perforators (p=0.008). Selection of the largest perforator of DIEP flap is advantageous in terms of continuity with the SIEA. Also, near the umbilicus, medial perforators communicate with the SIEA more than lateral perforators.

Prophylactic Venous Supercharging in Deep Inferior Epigastric Artery Perforator Flap Surgery: A Retrospective Dual-Center Study.

Deep inferior epigastric artery perforator (DIEP) flap is nowadays considered the gold standard in breast reconstruction. However, venous congestion is still a leading cause of free flap failure. Despite the conspicuous articles regarding the use of a secondary venous anastomosis, there is a lack in the literature regarding the prophylactic use of a secondary venous route to reduce the incidence of complications during breast reconstruction. A double-center retrospective study based on women undergoing DIEP breast reconstruction was conducted, dividing patients into case group (DIEP flaps with double venous anastomosis) and control group (DIEP flaps with single venous anastomosis). Demographic and surgical data and complications were compared and statistically analyzed, and a reconstructive algorithm was proposed to improve the flap insetting. In total, 154 patients were included in the study, divided into case group (74 patients) and control group (80 patients). The median age at the time of surgery was 49.09 years (range: 29-68 years), slightly lower in group 1 when compared with group 2. The mean body mass index (BMI) was 25.52 kg/m2 (range: 21.09-29.37 kg/m2), in particular 25.47 kg/m2 (range: 23.44-28.63 kg/m2) in group 1 and 25.58 kg/m2 (range: 21.09-29.37 kg/m2) in group 2. No statistical differences were found between groups in terms of BMI and smoking and comorbidities history. The average operative times were 272.16 minutes (range: 221-328 minutes) in group 1 and 272.34 minutes (range: 221-327 minutes) in group 2, with no significant difference between groups, as well as ischemia time (44.4 minutes in group 1 [range: 38-56 minutes] and 49.12 minutes in group 2 [range: 41-67 minutes]). Statistical analysis showed a reduction in short-term complications and a statistically significant reduction for take-backs in the two groups. Our study suggests that venous supercharging of DIEP flap by performing dual venous anastomosis can be routinely and safely done prophylactically, and thus not only after intraoperative assessment of venous congestion, to avoid flap venous congestion and decrease the rates of re-exploration.

Effectiveness of the proximal medial branch in DIEP flaps for breast reconstruction using Hartrampf zone IV

BackgroundWhen performing breast reconstruction using a deep inferior epigastric artery perforator (DIEP) flap, including Hartrampf zone IV, the bipedicled DIEP flap has been argued to be necessary to ensure stable perfusion. However, a proximal medial branch (PMB), which is the most proximal perforator of the deep inferior epigastric artery, may make it possible to obtain adequate perfusion in a unilateral DIEP flap. This study aimed to clarify the detailed anatomical characteristics of PMB and its potential clinical application in breast reconstruction. MethodsThis retrospective study was conducted on breast reconstruction using the DIEP flap between May 2020 and July 2023. Data on PMB anatomy were collected from preoperative contrast-enhanced computed tomography angiography, and contralateral perfusion of the flap was estimated using intraoperative indocyanine green angiography. ResultsThe PMB was present in approximately 85% of cases, arising near the lateral border of the rectus abdominis, branching caudomedially in over half of the cases, and perforating 2.3cm laterally and 8.8cm caudally on average from the umbilicus. The average perfusion area of both zones II and IV significantly expanded to 96.5% and 74.2%, respectively, when the PMB was included in the DIEP flap, and 9 of 22 cases showed contrast extending to the entire zone IV. ConclusionsThe use of the DIEP flap with PMB is a good option for substantial-volume breast reconstruction. When utilizing the PMB, it is important to consider its specific anatomy, location of the main perforator, and pedicle length.

Perfusion area versus volume of the DIEP flap: A multivariable analysis of perforator and flap characteristics for estimation of perfusion area and volume

BackgroundThe extent of perfusion of a deep inferior epigastric artery perforator (DIEP) flap is a primary concern for surgeons. This study aimed to determine whether the flap area or volume can be estimated using perforator and flap characteristics. MethodsIntraoperative flap perfusion was assessed using indocyanine green angiography in patients who underwent DIEP flap breast reconstruction between November 2018 and February 2023. The area perfused by a single dominant perforator was delineated on the surface of the flap and measured using the ImageJ software. Multiple linear regression analysis was conducted to estimate the ‘perfusion ratio,’ defined as the perfused area divided by the total flap area. Potential predictor variables included flap size (cm2), flap thickness (mm), perforator diameter (mm), perforator rows (medial/lateral), vertical location of perforator (at or above/below the umbilicus), and perforator eccentricity (vertical distance from upper flap margin to perforator, cm). ResultsIn total, 101 patients were included in this analysis. The mean ‘perfusion ratio’ was 67.8% ± 11.5%, predicted by perforator diameter (p = 0.022) and vertical location below umbilicus (p < 0.001) with positive correlations and negatively correlated with flap thickness (p = 0.003) in the multivariable analysis. Both perfusion area and weight were predicted by perforator diameter, vertical location of perforator, flap size, and flap thickness (p < 0.001). The coefficient of determination (adjusted R2) for prediction of perfusion weight was higher than that for the perfusion area (75.5% vs. 69.4%). ConclusionsFlap volume, rather than area, is determined by a perforator of a given diameter and location.

Lower Abdominal vs. Lateral Thigh Perforator Flaps in Microsurgical Sarcoma Reconstruction: The Aesthetics of Donor Site Matters.

Introduction: Sarcoma resection often leaves patients with big defects only amenable through microsurgical reconstruction. In such cases, it is hard for the surgeon to uphold low donor-site morbidity with an aesthetic result. The purpose of this study was to investigate the clinical outcome and the patient's perception regarding the donor site in a cohort of patients undergoing microsurgical reconstruction with lateral thigh and lower abdominal perforator flaps. Methods: A retrospective evaluation of all patients who underwent sarcoma reconstruction with flaps harvested from the lower abdominal region (deep inferior epigastric artery perforator flap, superficial circumflex iliac artery perforator flap) or lateral thigh region (anterolateral thigh perforator flap and its variations) was performed. Only patients with defects greater than 100 cm2 were included. Patient demographics and operative variables were recorded, together with complications. Patient satisfaction and quality of life with the donor site were registered using the SCAR-Q questionnaire, which was administered at least six months post-operatively. Results: Eighteen anterolateral thigh (ALT) perforator flaps and twenty-two deep inferior epigastric artery perforator (DIEP) and superficial circumflex iliac artery perforator (SCIP) flap procedures were performed. The two groups were homogeneous for major post-operative complications (p > 0.999). Patient satisfaction with the donor site measured using the SCAR-Q questionnaire showed significantly higher scores in the DIEP/SCIP group when compared with the thigh group (p < 0.001), indicating a superiority of the lower abdominal area as an aesthetic donor site. Conclusions: The DIEP and SCIP flaps are a versatile option for reconstructing large soft-tissue defects following sarcoma resection. Therefore, flaps harvested from the lower abdomen yield a higher patient satisfaction with the donor site, which is a feature worth considering when planning a reconstructive procedure.

A Multi-institutional Analysis of a Textbook Outcome Among Patients Undergoing Microvascular Breast Reconstruction.

Individual outcomes may not accurately reflect the quality of perioperative care. Textbook outcomes (TOs) are composite metrics that provide a comprehensive evaluation of hospital performance and surgical quality. This study aimed to investigate the prevalence and predictors of TOs in a multi-institutional cohort of patients who underwent breast reconstruction with deep inferior epigastric artery perforator flaps. For autologous reconstruction, a TO was previously defined as a procedure without intraoperative complications, reoperation, infection requiring intravenous antibiotics, readmission, mortality, systemic complications, operative duration ≤12 hours for bilateral and ≤10 hours for unilateral/stacked reconstruction, and length of stay (LOS) ≤5 days. We investigated associations between patient-level factors and achieving a TO using multivariable regression analysis. Of 1000 patients, most (73.2%) met a TO. The most common reasons for deviation from a TO were reoperation (9.6%), prolonged operative time (9.5%), and prolonged LOS (9.2%). On univariate analysis, tobacco use, obesity, widowed/divorced marital status, and contralateral prophylactic mastectomy or bilateral reconstruction were associated with a lower likelihood of TOs (P < 0.05). After adjustment, bilateral prophylactic mastectomy (odds ratio [OR], 5.71; P = 0.029) and hormonal therapy (OR, 1.53; P = 0.050) were associated with a higher likelihood of TOs; higher body mass index (OR, 0.91; P = <0.001) was associated with a lower likelihood. Approximately 30% of patients did not achieve a TO, and the likelihood of achieving a TO was influenced by patient and procedural factors. Future studies should investigate how this metric may be used to evaluate patient and hospital-level performance to improve the quality of care in reconstructive surgery.