Inferior Epigastric Perforator Flap Breast Research Articles

ASO Visual Abstract: Simultaneous Co-surgeon Deep Inferior Epigastric Perforator (DIEP) Flap Breast Reconstructions-Feasibility and Clinical Outcomes.

ASO Visual Abstract: Simultaneous Co-surgeon Deep Inferior Epigastric Perforator (DIEP) Flap Breast Reconstructions-Feasibility and Clinical Outcomes.

Projected augmented reality in DIEP flap breast reconstruction: Projecting perforators on the skin using dynamic infrared thermography

BackgroundDynamic infrared thermography (DIRT) is a quick and non-invasive technique for perforator mapping in free flaps that provides real-time information. After a cold challenge, areas best supplied with blood become visible hotspots on color-coded maps, indicating perforators. This study presents a proof of principle for a new and innovative feature of DIRT, where projected augmented reality is used to directly display thermal images on the patient’s abdomen prior to the deep inferior epigastric artery perforator (DIEP) flap breast reconstruction. MethodsA self-aligning projection device prototype (Anatomy Projector) equipped with an integrated thermal camera was used to obtain thermal information and project the color-coded map directly on the patient’s abdomen before DIEP flap breast reconstruction. Projected DIRT hotspots were verified using a hand-held Doppler, and compared to the vascularity on computed tomography angiography (CTA), and intraoperative perforator measurements following a Cartesian grid. ResultsA total of 514 DIRT hotspots were projected in 50 patients, among them 97.3% could be verified using Doppler. The positive predictive value for CTA was 74.5%. Intraoperative measurements yielded 132 perforators in 71 flaps, among them 75 perforators (56.8%) correlated with projected DIRT hotspots, and half of them (54.7%) appeared within the first 5 emerging hotspots. ConclusionThis study showed that real-time display of thermal data in DIEP flap breast reconstruction is feasible via projected augmented reality. Projection facilitates convenient marking of hotspots, and a high resemblance to Doppler and CTA data was observed. Further research should assess the added value of projecting thermal images intraoperatively and in other fields of plastic surgery.

Minimally Invasive Robotic-assisted Perforator-to-Perforator DIEP Flap Breast Reconstruction.

Reducing morbidity has been the goal of many reconstructive microsurgery efforts. Several techniques have been described for deep inferior epigastric perforator flap breast reconstruction to minimize abdominal donor-site morbidity. Although these techniques have certain tradeoffs, we designed a minimally invasive robot-assisted perforator-to-perforator approach to achieve minimal donor- and recipient-site morbidity. Simultaneous identification of the deep inferior epigastric artery (DIEA) and internal mammary artery (IMA) perforator was performed, followed by a small fascial incision around the dominant DIEA perforator. The IMA perforator was prepared for a prepectoral anastomosis. The short DIEA pedicle was dissected without further longitudinal fascial incision until an adequate diameter compared with the IMA perforator was reached, and a robot-assisted perforator-to-perforator anastomosis was performed prepectorally. All patients underwent reconstruction performed by a single surgeon. The smallest abdominal incision was 2.5 cm with a DIEP pedicle length of 6 cm. The average IMA perforator diameter was 1.14 mm (1.0 mm-1.2 mm). The average vein diameter was 2.0 mm (1.5-3.0 mm). The incision to closure lasted 330 minutes (313-348 minutes). Flap ischemia was 105 minutes (82-118 minutes), whereas the time for robot-assisted anastomosis was 25 minutes (22-30 minutes). All anastomoses were performed successfully. Our initial experience with robot-assisted perforator-to-perforator anastomosis for DIEP flap breast reconstruction demonstrates promise in achieving minimal patient morbidity. Raising only a very short pedicle can be compensated by adding the prepectoral IMA perforator length and enabling a good size match for small-caliber anastomosis. This technique combines important aspects of most minimally invasive DIEP flap harvests and insets.

D157. Intraoperative Indocyanine Green Angiography for Detecting Quantitative Flap Perfusion Changes in Deep Inferior Epigastric Perforator Flap Breast Reconstruction with Second Venous Drainage

D157. Intraoperative Indocyanine Green Angiography for Detecting Quantitative Flap Perfusion Changes in Deep Inferior Epigastric Perforator Flap Breast Reconstruction with Second Venous Drainage

The value of microvascular breast reconstruction: Cost equivalence of TRAM and DIEP flaps implications in the era of CMS reforms.

Recent CMS billing changes have raised concerns about insurance coverage for deep inferior epigastric perforator (DIEP) flap breast reconstruction. This study compared the costs and utilization of transverse rectus abdominis myocutaneous (TRAM), DIEP, and latissimus dorsi (LD) flaps in breast reconstruction. The study utilized the National Inpatient Sample database to identify female patients who underwent DIEP, TRAM, and LD flap procedures from 2016 to 2019. Key data such as patient demographics, length of stay, complications, and costs (adjusted to 2021 USD) were analyzed, focusing on differences across the flap types. A total of 17,770 weighted patient encounters were identified, with the median age being 51. The majority underwent DIEP flaps (73.5%), followed by TRAM (14.2%) and LD (12.1%) flaps. The findings revealed that DIEP and TRAM flaps had a similar length of stay (LOS), while LD flaps typically had a shorter LOS. The total hospital charges to costs using cost-to-charge ratio were also comparable between DIEP and TRAM flaps, whereas LD flaps were significantly less expensive. Factors such as income quartile, primary payer of hospitalization, and geographic region significantly influenced flap choice. The study's results appear to contradict the prevailing notion that TRAM flaps are more cost-effective than DIEP flaps. The total hospital charges to costs using cost-to-charge ratio and hospital stays associated with TRAM and DIEP flaps were found to be similar. These findings suggest that changes in the insurance landscape, which may limit the use of DIEP flaps, could undermine patient autonomy while not necessarily reducing healthcare costs. Such policy shifts could favor less costly options like the LD flap, potentially altering the landscape of microvascular breast reconstruction.

Simultaneous Co-surgeon Deep Inferior Epigastric Perforator (DIEP) Flap Breast Reconstructions: Feasibility and Clinical Outcomes.

A co-surgeon model is known to be favorable in microvascular breast reconstruction, but simultaneous co-surgeon deep inferior epigastric perforator (DIEP) flap cases have not been well-studied. The authors hypothesize that performing two simultaneous co-surgeon bilateral DIEP flap reconstructions results in non-inferior clinical outcomes and may improve patient access to care. A single-institution, retrospective cohort study was performed utilizing record review to identify all cases of co-surgeon free-flap breast reconstructions over a 38-month period. Patients who underwent simultaneous bilateral DIEP flap breast reconstructions with the same two co-surgeons were identified. The control group consisted of subjects who underwent non-simultaneous reconstruction by the same co-surgeons within the same, preceding, or following month of those in the study group. Primary outcome variables were 90-day postoperative complications, while secondary outcomes were operating time, ischemia time, and length of stay. Descriptive statistics, univariate and multivariable regression analyses were performed. Overall, 137 subjects were identified and 64 met the inclusion criteria (n=28 study, n=36 control). There were no statistically significant differences between groups in body mass index, radiation, trainee experience, flap perforator number, immediate/delayed reconstruction, or length of stay. There were also no statistically significant differences in complications, including flap loss, anastomosis revision, take-back to the operating room, or re-admission. Operative time was longer in the simultaneous DIEP group (540.5 vs. 443.5 min, p<0.01), but ischemia time was shorter in the simultaneous group (64.0 vs. 80.5min, p<0.01). A simultaneous co-surgeon approach to bilateral DIEP flap reconstruction may improve access to care and does not result in a higher complication rate compared with non-simultaneous bilateral DIEP flaps.

Social Determinants of Health and Patient-reported Outcomes Following Autologous Breast Reconstruction, Using Insurance as a Proxy.

Insurance type can serve as a surrogate marker for social determinants of health and can influence many aspects of the breast reconstruction experience. We aimed to examine the impact of insurance coverage on patients reported outcomes with the BREAST-Q (patient reported outcome measure for breast reconstruction patients, in patients receiving) in patients receiving deep inferior epigastric artery perforator (DIEP) flap breast reconstruction. We retrospectively examined patients who received DIEP flaps at our institution from 2010 to 2019. Patients were divided into categories by insurance: commercial, Medicaid, or Medicare. Demographic factors, surgical factors, and complication data were recorded. Descriptive statistics, Fisher's exact, Kruskal-Wallis rank sum tests, and generalized estimating equations were performed to identify associations between insurance status and five domains of the BREAST-Q Reconstructive module. A total of 1,285 patients were included, of which 1,011 (78.7%) had commercial, 89 (6.9%) had Medicaid, and 185 (14.4%) had Medicare insurances. Total flap loss rates were significantly higher in the Medicare and Medicaid patients as compared to commercial patients; however, commercial patients had a higher rate of wound dehiscence as compared to Medicare patients. With all other factors controlled for, patients with Medicare had lower Physical Well-being of the Chest (PWBC) than patients with commercial insurance (β = - 3.1, 95% confidence interval (CI): -5.0, -1.2, p = 0.002). There were no significant associations between insurance classification and other domains of the BREAST-Q. Patients with government-issued insurance had lower success rates of autologous breast reconstruction. Further, patients with Medicare had lower PWBC than patients with commercial insurance regardless of other factors, while other BREAST-Q metrics did not differ. Further investigation as to the causes of such variation is warranted in larger, more diverse cohorts.

Initial Experience with Unidirectional Barbed Suture for Abdominal Donor Site Closure in Deep Inferior Epigastric Perforator Flap Breast Reconstruction.

The deep inferior epigastric perforator (DIEP) flap is a predominant technique for autologous breast reconstruction. However, the best method of abdominal fascial closure in this technique is not well defined. This study details our initial experience with unidirectional barbed suture-only repair of abdominal donor site fascia. Patients who underwent DIEP flap breast reconstruction and abdominal fascial closure with Stratafix Symmetric Polydioxanone PDS Plus were retrospectively reviewed. Information regarding pertinent patient history, medical comorbidities, risk factors, and surgical technique was extracted, along with the incidence of eight separate postoperative abdominal surgical site occurrences. Retrospective review identified 43 patients who underwent 19 unilateral and 24 bilateral DIEP flap breast reconstruction procedures (n = 67). Average patient follow-up was 791 days (range 153-1769). Six patients (14%) had a complication of the donor site. Seroma was most frequent (n = 3, 7%), followed by surgical site infection (n = 2, 5%). One patient had incisional dehiscence (2%) and another patient developed bulging (2%). No patients had chronic pain, weakness, hematoma, or hernia postoperatively. Patients with donor site complications had a history of abdominal/pelvic surgery significantly more often than the patients without donor site complications (100% versus 49%; P = 0.032). Abdominal fascial repair with Stratafix Symmetric suture alone led to low rates of abdominal donor site morbidity, including no hernia and rare bulging, following DIEP flap breast reconstruction. Additional advantages of this technique may be reduced operative times and lower operative costs compared with alternative methods of fascial repair, although prospective and randomized studies are warranted.

Reversal in Centers for Medicare & Medicaid Services Reimbursement for Deep Inferior Epigastric Perforator Flap Reconstruction-Empowering Plastic Surgeons in Sustaining Microsurgical Accessibility.

This Editorial discusses the recent overturning of a proposed Centers for Medicare & Medicaid Services policy that reduced reimbursement for deep inferior epigastric perforator flap breast reconstruction. The authors highlight the importance of advocacy efforts in sustaining access to complex microsurgical procedures, even those under investigation such as breast reinnervation and lymphatic reconstruction.

Evaluating the Impact of Prior Abdominal Surgeries and Mesh Use on Abdominal Wall Morbidity after Deep Inferior Epigastric Perforator (DIEP) Flap Breast Reconstruction

Evaluating the Impact of Prior Abdominal Surgeries and Mesh Use on Abdominal Wall Morbidity after Deep Inferior Epigastric Perforator (DIEP) Flap Breast Reconstruction

Microneedling in Abdominal Scarring after DIEP-flap Breast Reconstruction to Improve Scar Quality: A Randomized Controlled Split Scar Trial.

Deep inferior epigastric perforator (DIEP) flap breast reconstruction leads to large scars in the breast and abdominal region. Common symptoms related to abdominal scarring include changes in color, stiffness, thickness, and irregularity of the skin. The aim of this study was to examine whether microneedling improves the abdominal scar quality after DIEP-flap breast reconstruction. A prospective randomized controlled within subject comparison design (N = 30) was used to study the effect of microneedling treatments on the abdominal scar, versus no treatment. Three electrically powered microneedling sessions were performed every 4 weeks on one side of the abdominal scar. Abdominal scar assessment was performed at baseline and 3-, 6-, and 9-month follow-up using the Patient and Observer Scar Assessment Scale (POSAS). Treated and untreated sides were compared using a t test or Wilcoxon signed-rank test in case the data were not normally distributed. Twenty-seven women completed the study. Microneedling treatment led to lower POSAS scores compared with the untreated scar side after the 3- and 9-month follow-up. At the 9-month follow-up, the POSAS total score (Mdn = 17, interquartile range = 18.3 versus Mdn = 21.4, interquartile range = 17.5) was statistically lower for the treated side compared with the untreated side, implying a better-appraised scar quality. The observer POSAS total score was statistically lower for the treated side compared with the untreated side. Based on patient and observer ratings, overall abdominal scars after DIEP-flap surgery improve significantly after microneedling treatment. Scar symptoms reduce faster under the influence of microneedling treatment compared with no treatment.

The Full Continuum of Robotic Breast Surgery: Robotic-assisted Mastectomy, Robotic DIEP Flap, and Robotic Supermicrosurgery

Summary: In recent years, robotic surgery has rapidly expanded to improve surgical outcomes in a variety of surgical subspecialties. Although plastic surgery has taken longer to integrate robotic surgery into practice, the advantages of robotic-assisted surgery, including improved visualization and resolution, minimally invasive approaches, and the ability to surpass human precision and scale, have driven its more recent adoption into plastic surgery. Currently, procedures performed with robotic assistance that are considered part of the continuum of surgical treatment of breast cancer include robotic-assisted nipple-sparing mastectomy, reconstruction with the robotic latissimus dorsi flap or the deep inferior epigastric artery perforator flap, and robotic microsurgery for the flap anastomosis and/or the surgical treatment of lymphedema. The authors provide an overview of robotic surgery and how it has been integrated into the field of plastic surgery, as well as a review of the most common procedures within the field where robotic assistance can be incorporated: nipple-sparing mastectomy, robotic latissimus flap, robotic deep inferior epigastric artery perforator flap breast reconstruction, and microvascular anastomoses.

Dobutamine and Goal-Directed Fluid Therapy for Improving Tissue Oxygenation in Deep Inferior Epigastric Perforator (DIEP) Flap Breast Reconstruction Surgery: Protocol for a Randomized Controlled Trial.

Breast reconstruction is an integral part of breast cancer care. There are 2 main types of breast reconstruction: alloplastic (using implants) and autologous (using the patient's own tissue). The latter creates a more natural breast mound and avoids the long-term need for surgical revision-more often associated with implant-based surgery. The deep inferior epigastric perforator (DIEP) flap is considered the gold standard approach in autologous breast reconstruction. However, complications do occur with DIEP flap surgery and can stem from poor flap tissue perfusion/oxygenation. Hence, the development of strategies to enhance flap perfusion (eg, goal-directed perioperative fluid therapy) is essential. Current perioperative fluid therapy is traditionally guided by subjective criteria, which leads to wide variations in clinical practice. The main objective of this trial is to determine whether the use of minimally invasive cardiac output (CO) monitoring for guiding intravenous fluid administration, combined with low-dose dobutamine infusion (via a treatment algorithm), will increase tissue oxygenation in patients undergoing DIEP flap surgery. With appropriate institutional ethics board and Health Canada approval, patients undergoing DIEP flap surgery are randomly assigned to receive CO monitoring for the guidance of intraoperative fluid therapy in addition to a low-dose dobutamine infusion (which potentially improves flap oxygenation) versus the current standard of care. The primary outcome is tissue oxygenation measured via near-infrared spectroscopy at the perfusion zone furthest from the perforator vessels 45 minutes after vascular reanastomosis of the DIEP flap. Low dose (2.5 μg/kg/hr) dobutamine infusion continues for up to 4 hours postoperatively, provided there are no associated complications (ie, persistent tachycardia). Flap oxygenation, hemodynamic parameters, and any medication-associated side effects/complications are monitored for up to 48 hours postoperatively. Complications, rehospitalizations, and patient satisfaction are also collected until 30 days postoperatively. Funding and regulatory approvals were obtained in 2019, but the study recruitment was interrupted by the COVID-19 pandemic. As of October 4, 2023, 34 participants have been recruited. Because of the significant delays associated with the pandemic, the expected completion date was extended. We expect the study to be completed and ready for potential news release (as appropriate) and publication by July 2024. No patients have suffered any adverse effects/complications from participating in this study, and none have been lost to follow-up. CO-directed fluid therapy in combination with a low-dose dobutamine infusion via a treatment algorithm has the potential to improve DIEP flap tissue oxygenation and reduce complications following DIEP flap breast reconstruction surgery. However, given that the investigators remain blinded to group randomization, no comment can be made regarding the efficacy of this intervention for improving tissue oxygenation at this time. Nevertheless, no patients have been withdrawn for safety concerns thus far, and compliance remains high. Clinicaltrials.gov NCT04020172; https://clinicaltrials.gov/study/NCT04020172.

Impact of Post-Mastectomy Radiotherapy on Cosmesis and Quality of Life after Deep Inferior Epigastric Perforator Flap Breast Reconstruction: A Single Institution Experience

Immediate breast reconstruction (IBR) yields better cosmetic results and reduce psychological distress than delayed (DBR). Literature data showed better local cosmesis after reconstruction autologous flaps than prothesis. Our aim is to compare cosmetic results and quality of life (QoL) after PMRT delivered either after IBR or DBR with DIEP flap. We reviewed files of 99 patients (100 DIEPs) treated in our department from January 2000 to December 2019. Patients were divided into 2 groups depending on the treatment sequence: IBR (n = 22) versus DBR (n = 78) followed by PMRT. All the patients had their DIEP flap by the same surgical team. All patients had cosmetic evaluation using Harvard/RTOG cosmesis grading scale. Fifty percent (32 in IBR and 14 in DBR group) of the patients responded to the QoL evaluation using auto questionnaires and BREAST-Q to evaluate breast specific HRQoL and satisfaction. The analysis of cosmetic scores was carried out with a Chi2 test and the analysis of QoL scores with a student test. Kaplan Meier (log-rank test) is used for recurrence-free and overall survival. Median follow-up was 56 months. Median age of the patients was 48 (28-71). In terms of disease stage: T1-2 (52%), N0 (38%). 86% of the patients had chemotherapy either in neo-adjuvant (26%) or adjuvant (60%) settings. Radiation therapy (RT) delivered a total dose ranged between 45 Gy and 50 Gy using 1.8-2.5 Gy/per fraction. Supra-clavicular and internal mammary chain irradiation was performed in 67% and 33% of the patients respectively. After surgery, 15% had post-operative complications such as DIEP necrosis (n = 8) that delayed RT delivery. Among the 99 patients, 3 died from metastatic evolution and were not included in the cosmetic and QoL analyses. Local recurrence rate was slightly higher after DBR (12.5%) as compared to IBR (3.8%). Loco-regional and metastatic recurrence rates were 4.5% and 4.5% after IBR versus 1.3% and 9% after DBR (p = NS). Disease free and overall survival were 88% and 98% at 5y and 66% and 96% at 10y.Good-to-excellent results were observed in 57% in the IBR vs 67% in the DBR (p = 0.92). There was no impact of previous chemotherapy (p = 0.21), tobacco use at diagnosis (p = 0.27), diabetes (p = 0.86), RT timing (p = 0.53) and endocrine therapy administration (p = 0.67). QoL was evaluated with the BREAST-Q self-evaluation for 5 post operative items: psycho-social, physical, sexual well-being and satisfaction with breast and global cosmetic results. Out of the 99 patients, 46% had responded to the QoL evaluation. We found no statistical difference between the two groups for all the BREAST-Q evaluation items. Our center is considered expert for DIEP reconstructions since its development in end of the nineties. Our data showed no impact PMRT using conventional fractionation (with mainly 1.8 Gy/fraction) on cosmetic results, QoL, and patients' satisfaction regardless of the timing of the breast reconstruction. Additional studies are in progress with updates.

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

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

Preoperative planning using virtual reality and computed tomography angiogram in deep inferior epigastric perforator flap breast reconstruction

The gold standard for preoperative planning of deep inferior epigastric perforator (DIEP) flap breast reconstruction uses computed tomography angiography (CTA). Virtual reality (VR) circumnavigates the limitations of CTA by reconstructing a fully immersive and interactive 3D representation of the scan. Scans of 44 patients who underwent DIEP flap breast reconstruction were retrospectively reviewed and compared using CTA and VR imaging modalities. The objective of this research was to compare perforators found using VR to the ones identified using conventional CTA. A correlation was found between the imaging modalities for unilateral (R = 0.96 (CI = 0.92, 0.98)) and bilateral (R = 0.93, (CI = 0.83, 0.97)) DIEP flap surgeries when comparing perforator location related to the umbilicus. Multivariable ordinal logistic regression found that higher intramuscular course length (IMC) is associated with the number of perforators found per side (OR = 1.79 (CI = 1.24, 2.6)), and medial location (OR = 2.85 (CI = 1.38, 5.87)). Larger vessel caliber (VC) is associated with shorter IMC (T2 vs. T3, OR = 3.34 (CI = 1.49, 7.49)), and branching in adipose tissue (AB) is associated with higher VC (T1 vs. T3, OR = 0.02 (CI = 0.007, 0.08); T2 vs. T3, OR = 0.24 (CI = 0.11, 0.55)). Overall, preoperative planning using VR was easy to use, safe, more intuitive, and provided in a time-efficient manner, more information about perforant characteristics. VR can improve the surgeon’s decision accuracy, relating to the best perforators for harvesting, in a shorter time period.

Operative Time Predicts Long-Term Abdominal Morbidity and Complication Requiring Treatment after DIEP Flap Breast Reconstruction.

The relationship between skin-to-skin operative time and long-term complications, as well as complications requiring treatment, after deep inferior epigastric perforator (DIEP) flap breast reconstructions has not been thoroughly investigated. The study objective was to evaluate if operative time would independently prognosticate the type and number of treated complications, as well as long-term abdominal morbidity. Patients who underwent bilateral DIEP flaps from 2010 to 2021 by two senior surgeons with standardized surgical and postoperative protocols were retrospectively reviewed. Inclusion required at least 1 year of postoperative follow-up. Extensive multivariable regression analyses were utilized to adjust for potential confounders, including measures of intraoperative complexity. Three hundred thirty-five patients were entered into multivariable analyses. After risk adjustment, there was a significant increase in the risk of all treated complications per hour. Each hour of operation increased risk of complications requiring extended hospital stay for treatment by 25%, flap-site complications requiring readmission treatment by 24%, and flap-site complications requiring extended hospital stay for treatment by 26% (all p < 0.0001). Long-term abdominal morbidity (abdominal bulge) increased by 25% per hour of operative time (p < 0.0001). The number of complications requiring treatment, abdominal donor-site complications, and complications requiring extended hospital stay for treatment had statistically significant linear relationships with the duration of surgery (all p < 0.05). Operative time predicts long-term abdominal morbidity and complications requiring treatment, especially impacting the odds of developing abdominal bulges and complications requiring extended hospital stay for treatment or readmission treatment. This study emphasizes the importance of reducing operative time to improve DIEP flap breast reconstruction outcomes.

Improving Visualization of Intramuscular Perforator Course: Augmented Reality Headsets for DIEP Flap Breast Reconstruction.

Augmented reality (AR) technology, exemplified by devices such as the Microsoft HoloLens 2, has gained interest for its potential applications in preoperative guidance. This study explores the use of AR technology for perforator identification during deep inferior epigastric artery perforator (DIEP) flap breast reconstruction. A case series of five patients where an AR device was used to identify perforators during DIEP flap breast reconstruction is presented. The device was utilized to recognize preoperative perforators and map their extra- and intramuscular routes. Sound and/or color Doppler confirmation was used to verify the findings. In all five cases, the AR device successfully identified preoperative perforators and delineated their extra- and intramuscular routes. AR technology in perioperative visualization of vasculature offers the potential to enhance surgical precision and reduce operative times. By providing an augmented three-dimensional overlay of patients' vascular structures, AR can facilitate a more comprehensive understanding of individual anatomy, ultimately improving surgical outcomes. AR technology shows promise in enhancing perforator identification efficiency and deepening understanding of perforator trajectories during preoperative planning. Nonetheless, additional research is needed to establish whether the advantages of AR technology warrant its widespread adoption for perforator identification.

Prolonged operative time is a risk factor for adverse postoperative outcomes in the unilateral deep inferior epigastric perforator (DIEP) flap surgery: A retrospective cohort study

Currently, one published study documented operative time (OT) as a predictor for postoperative outcomes in bilateral deep inferior epigastric perforator (DIEP) flap breast reconstructions. No literature has investigated this in unilateral DIEP flaps. We aimed to determine the relationship between unilateral OT, postoperative complications, unplanned reoperations (UR), and extended length-of-stay (eLOS). Patients who underwent elective unilateral DIEP reconstruction from 2018 to 2023 at a tertiary centre in London, United Kingdom, were retrospectively analysed. Patients were divided into four groups depending on OT quartiles to define a critical cut-off period. Data on extensive covariates, including procedural complexity, was recorded and used in univariable and multivariable regression models. The final cohort contained 173 patients. After risk-adjustment, ≥421-minute operations led to a significantly higher overall complication rate (HR: 2.14, 95% CI: 1.26, 3.64, p=0.005) relative to <421min. Significantly higher odds of eLOS were observed in the ≥460-minute group (OR: 2.07, 95% CI: 1.07, 3.99, p=0.03) compared to <460min. There was no significant effect on the rate of postoperative UR across any OT group. We confirmed OT was an independent predictor for postoperative outcomes in the DIEP flap, and demonstrated this in unilateral reconstructions. A clinical maximum threshold of 7h was derived based on this cohort to help guide future surgical practice. Efficiency can be achieved by meticulous preoperative planning and process standardisation, multiple senior surgeons working per flap, and smooth teamwork between specialities and intraoperative staff.

Venous Thromboembolism after Deep Inferior Epigastric Perforator Flap Breast Reconstruction: Review of Outcomes After a Postoperative Prophylaxis Protocol.

Deep inferior epigastric perforator (DIEP) flap breast reconstruction is among the higher-risk patient groups for venous thromboembolism (VTE) in plastic surgery. Surgeons often opt for a patient-specific approach to postoperative anticoagulation, and the field has yet to come to a consensus on VTE chemoprophylaxis regimens. A new chemoprophylaxis protocol was introduced starting March 2019 that involved two weeks of treatment with enoxaparin, regardless of patient risk factors. A retrospective chart review was conducted on all patients who underwent DIEP flap breast reconstruction at our institution between January 2014 and March 2020. Patients were grouped based on whether they enrolled in the new VTE protocol in the postoperative period or not. Patient demographics, prophylaxis type, and outcomes data were recorded, retrospectively. The primary outcome measure was postoperative VTE incidence. Risk of VTE was significantly higher in patients discharged without VTE prophylaxis compared to patients discharged with prophylaxis (3.7% vs. 0%, p = 0.03). Notably, zero patients in the VTE prophylaxis group developed a DVT or PE. Additionally, the risk of a VTE event was 25 times greater in patients with a Caprini score greater than or equal to 6 (p=0.0002). We demonstrate the successful implementation of a two-week VTE chemoprophylaxis protocol in DIEP flap breast reconstruction patients that significantly reduces the rate of VTE while not affecting the rate of hematoma complications.