Inferior Epigastric Perforator Flap Reconstruction Research Articles

Advancing DIEP Flap Monitoring with Optical Imaging Techniques: A Narrative Review

Objectives: This review aims to explore recent advancements in optical imaging techniques for monitoring the viability of Deep Inferior Epigastric Perforator (DIEP) flap reconstruction. The objectives include highlighting the principles, applications, and clinical utility of optical imaging modalities such as near-infrared spectroscopy (NIRS), indocyanine green (ICG) fluorescence angiography, laser speckle contrast imaging (LSCI), hyperspectral imaging (HSI), dynamic infrared thermography (DIRT), and short-wave infrared thermography (SWIR) in assessing tissue perfusion and oxygenation. Additionally, this review aims to discuss the potential of these techniques in enhancing surgical outcomes by enabling timely intervention in cases of compromised flap perfusion. Materials and Methods: A comprehensive literature review was conducted to identify studies focusing on optical imaging techniques for monitoring DIEP flap viability. We searched PubMed, MEDLINE, and relevant databases, including Google Scholar, Web of Science, Scopus, PsycINFO, IEEE Xplore, and ProQuest Dissertations & Theses, among others, using specific keywords related to optical imaging, DIEP flap reconstruction, tissue perfusion, and surgical outcomes. This extensive search ensured we gathered comprehensive data for our analysis. Articles discussing the principles, applications, and clinical use of NIRS, ICG fluorescence angiography, LSCI, HSI, DIRT, and SWIR in DIEP flap monitoring were selected for inclusion. Data regarding the techniques’ effectiveness, advantages, limitations, and potential impact on surgical decision-making were extracted and synthesized. Results: Optical imaging modalities, including NIRS, ICG fluorescence angiography, LSCI, HSI, DIRT, and SWIR offer a non- or minimal-invasive, real-time assessment of tissue perfusion and oxygenation in DIEP flap reconstruction. These techniques provide objective and quantitative data, enabling surgeons to monitor flap viability accurately. Studies have demonstrated the effectiveness of optical imaging in detecting compromised perfusion and facilitating timely intervention, thereby reducing the risk of flap complications such as partial or total loss. Furthermore, optical imaging modalities have shown promise in improving surgical outcomes by guiding intraoperative decision-making and optimizing patient care. Conclusions: Recent advancements in optical imaging techniques present valuable tools for monitoring the viability of DIEP flap reconstruction. NIRS, ICG fluorescence angiography, LSCI, HSI, DIRT, and SWIR offer a non- or minimal-invasive, real-time assessment of tissue perfusion and oxygenation, enabling accurate evaluation of flap viability. These modalities have the potential to enhance surgical outcomes by facilitating timely intervention in cases of compromised perfusion, thereby reducing the risk of flap complications. Incorporating optical imaging into clinical practice can provide surgeons with objective and quantitative data, assisting in informed decision-making for optimal patient care in DIEP flap reconstruction surgeries.

Risk Factors for Skin Flap and Nipple-Areolar Necrosis in Patients Undergoing Nipple-Sparing Mastectomy With Deep Inferior Epigastric Perforator Flap Reconstruction.

Nipple-sparing mastectomy (NSM) with deep inferior epigastric perforator (DIEP) flap reconstruction is a surgical option for select patients with or at risk of breast cancer. However, post-operative skin flap and nipple-areolar complex (NAC) necrosis remain common complications. This study aimed to identify factors associated with necrosis in patients undergoing NSM with DIEP reconstruction. A retrospective cohort study was performed from 2015 to 2023. 74 variables were analyzed in patients undergoing NSM with DIEP. Patients were stratified into 3 groups based on post-operative skin/NAC necrosis: none, partial thickness, and full thickness. Comparative and descriptive statistics were performed via t-tests, ANOVA, and chi-squared tests. 34 women with 31 breast cancers met inclusion. 44% experienced necrosis: 15% partial thickness and 29% full thickness. The majority were white (85.3%) with mean age of 50 years (SD = 9.11). In patients with immediate DIEP reconstruction, hypoperfused areas identified by SPY angiography increased risk of necrosis (P = .012). Approximately 50% of both partial thickness and full thickness necrosis patients had concerns on SPY angiography. Former smokers in the full thickness necrosis group had more pack years than those without necrosis (9 vs .65 pack years, P = .035). In patients receiving NSM with DIEP flap reconstruction, those with hypoperfusion on SPY angiography and longer smoking history had higher necrosis rates. This supports the continued used of SPY angiography and the role of pre-operative counseling in former smokers with increased pack years on their risk of necrosis and the role of preventative measures in the perioperative setting.

Bridging the Gap: A Pilot Study on the Efficacy of Nerve Allografts in Autologous Breast Reconstruction

Background: Breast anesthesia is commonly reported after mastectomy and reconstruction. During deep inferior epigastric perforator (DIEP) flap reconstruction, we coapt at least one of the T10–12 thoracoabdominal nerves within the flap to the anterior cutaneous branch of the 3rd intercostal nerve using a nerve allograft. We aim to evaluate the efficacy of nerve grafting in improving sensory recovery following neurotized DIEP flap reconstruction. Methods: Thirty patients (54 breasts) underwent immediate neurotized DIEP flap reconstruction using nerve grafts. Sensitivity evaluation was performed in nine breast regions. For each patient, sensation was compared between two time points: 3 to 6 months postoperatively versus 12 to 24 months postoperatively. The reconstructive BREAST-Q was used to survey patients’ satisfaction of their breasts, physical wellbeing, psychosocial wellbeing, and sexual wellbeing. Results: At 3 to 6 months postoperatively, patients had a mean sensitivity measurement of 52.1 g/mm2. At 12 to 24 months postoperatively, patients had a mean sensitivity measurement of 40.3 g/mm2. There was a significant decrease in the mean cutaneous threshold required for patients to perceive sensation between the two time points (–29.1 percent, p = 0.041). On the reconstructive BREAST-Q, patients scored significantly higher in breast satisfaction (56.7/100 versus 75.1/100, +32.5 percent, p = 0.032) and physical wellbeing (66.0/100 versus 85.5/100, +20.2 percent, p = 0.022) between the two time points. Conclusions: Patients who undergo nerve graft-based DIEP flap reconstruction can expect significant improvements in sensation to pressure over time. This improvement found on sensory testing correlates with significant improvement in patients’ BREAST-Q scores.

Intra-abdominal pressure increases peri-operatively in patients undergoing deep inferior epigastric perforator flap reconstruction: A prospective study linking high intra-abdominal pressure to non-fatal lung embolism within one patient

The deep inferior epigastric perforator (DIEP) flap is the gold standard for autologous breast reconstruction. The procedure and peri-operative period are associated with the risk of severe post-operative complications, like venous thromboembolic events (VTE) and lung embolism. Whether the intra-abdominal pressure (IAP) increases after the closure of the abdominal defect, thereby potentially affecting the venous backflow and the risk of VTE, is currently not known. The primary aim is to test if the closure of the abdominal donor site increases the IAP in women undergoing secondary DIEP flap breast reconstruction. By using a Unometer, we measured the intravesical pressure as a surrogate marker for the IAP, at baseline, immediately after, and 24h after abdominal skin closure, for 13 patients. The mean IAP increased from 6.1mmHg (95% CI 4.6-7.7) at baseline to 9.0mmHg (95% CI 8.0-10.0) immediately after skin closure [mean diff. 2.9 (95% CI 1.0-4.8) (p=0.007)] and further up to 11.7mmHg (95% CI 9.0-14.5) 24h after closure [mean diff. 5.3 (95% CI 1.4-9.1) (p=0.012)]. We found that IAP varies among the patients, regardless of the tightness of abdominal closure or rectus plication (n=3). Immediately after closure, none of the isolated patients showed abnormal levels of IAP (>12mmHg), while eight out of 12 isolated patients (67%) showed IAP levels above the normal range after 24h. One patient developed a non-fatal lung embolism. The mean IAP increases significantly over the post-operative period after DIEP flap reconstruction, although abnormal IAP values are only seen 24h after the closure of the skin.

Evaluation of Intraoperative Anastomotic Patency with Angiography in Microsurgical Breast Reconstruction.

Microsurgical breast reconstruction is one of the most challenging, yet rewarding procedures performed by plastic surgeons. Several measures are taken to ensure safe elevation of the flap, preparation of recipient vessels, microvascular anastomosis, and flap inset. Reestablishing proper blood flow to the flap tissue after microvascular anastomosis is one of many critical steps for surgical success. Several measures to assess blood flow to the flap have been used; however, the use of indocyanine green angiography (ICGA) of the anastomosis in breast reconstruction has not been well documented. We present a series using ICGA for the evaluation of microvascular anastomosis success in breast reconstruction. Cases from patients who underwent microsurgical breast reconstruction between March 2022 and January 2023 and who had intraoperative ICGA were retrospectively reviewed. We compared the intraoperative findings on ICGA to flap success. Sixteen patients underwent bilateral deep inferior epigastric perforator flap reconstruction with intraoperative ICGA of the microvascular anastomosis, constituting 32 deep inferior epigastric perforator flaps. The ICGA demonstrated return of blood flow in all the flaps after microvascular anastomosis and no flap loss in our sample population. Nine flaps required additional drainage using the superficial inferior epigastric vein, and the superficial circumflex vein was used for additional drainage in one of the flaps. The use of intraoperative ICGA provides reliable visual feedback regarding the patency and direction of the blood flow through the microvascular anastomosed vessels. ICGA can be used as an additional tool in the plastic surgeon's armamentarium for successful breast reconstruction.

Skin deformation analysis for pre-operative planning of DIEAP flap reconstruction surgery.

Deep inferior epigastric artery perforator (DIEAP) flap reconstruction surgeries can potentially benefit from augmented reality (AR) in the context of surgery planning and outcomes improvement. Although three-dimensional (3D) models help visualize and map the perforators, the anchorage of the models to the patient's body during surgery does not consider eventual skin deformation from the moment of computed tomography angiography (CTA) data acquisition until the position of the patient while in surgery. In this work, we compared the 3D deformation registration from supine arms down (CTA position) to supine with arms at 90° degrees (surgical position), estimating the patient's skin deformation. We processed the data sets of 20 volunteers with a 3D rigid registration tool and performed a descriptive statistical analysis and statistical inference. With 2.45mm of root mean square and 2.89mm of standard deviation, results include 30% cases of deformation above 3mm and 15% above 4mm. Pose transformation deformation indicates that 3D surface data from the CTA scan position differs from data acquired in loco at the surgical table. Such results indicate that research should be conducted to construct accurate 3D models using CTA data to display on the patient, while considering projection errors when using AR technology.

Outcomes of DIEP flap reconstruction after pelvic cancer surgery: A retrospective multicenter case series

Flap reconstruction is often required after pelvic tumor resection to reduce wound complications. The use of perforator flaps has been shown to reduce donor site morbidity. The purpose of this study was to evaluate the outcomes of pedicled deep inferior epigastric perforator (pDIEP) flap reconstruction. This was a retrospective multicenter study of patients who underwent immediate pDIEP flap reconstruction for a pelvic or perineal defect after tumor resection between November 2012 and June 2022. The primary outcome was abdominal donor site morbidity, and the secondary outcome was perineal morbidity. Thirty-four patients (median age, 57.5 years) who underwent pelvic exenteration (n=31), extralevator abdominoperineal excision (n=2), or extended vaginal hysterectomy (n=1) were included. The most common indications were recurrent cervical (n=19) and anal (n=4) squamous cell carcinoma. Twenty-nine patients (85%) had a history of radiotherapy. Only one patient (3%) had major (Clavien-Dindo ≥ III) donor site complications (surgical site infection due to tumor recurrence). Eleven patients (32%) had at least one major recipient site complication (surgical site infection [n=1], total [n=2] or partial [n=1] flap loss, perineal dehiscence [n=2], hematoma [n=1], fistula [n=5]). No incisional or perineal hernias were observed during follow-up. Ninety-day survival was 100%. Pedicled DIEP flap reconstructions performed by experienced surgical teams had good outcomes for perineal or vaginal reconstruction, with low abdominal morbidity, in patients with advanced pelvic malignancies who had undergone median laparotomy. The risks and benefits of this procedure should be carefully evaluated preoperatively using clinical and imaging data.

Creating a context for recipient vessel selection in deep inferior epigastric perforator flap breast reconstruction

In autologous tissue breast reconstruction, recipient vessels are important for artery perfusion and venous drainage to ensure free flap survival. There are insufficient clinical outcomes to select efficient recipient vessels in bi-pedicled deep inferior epigastric perforator (DIEP) flap reconstruction. We presented a retrospective observational series of 108 patients regarding the diameter, anastomosis time, and re-anastomosis rate in internal mammary (IM), circumflex scapular (CS), thoracodorsal (TD), thoracoacromial (TA), lateral thoracic (LT), and internal mammary perforator (IMP) vessels of bi-pedicled DIEP flaps for breast reconstruction after mastectomy. The outcomes were the vessel re-anastomosis rate, flap failure rate, vessel anastomosis time, and complications. Data were gleaned from the chi-square test, Fisher's test, and analysis of variance using Scheffe's test as a post hoc analysis. The level of significance was p<0.05. There were no significant differences in the diameters of the artery, first vein, and second vein across the recipient vessels (p>0.05). However, the anastomosis time was longer in IM and TA than in CS, TD, and LT (p<0.001). Also, there were no significant differences for re-anastomosis, flap necrosis, and fat necrosis among different recipient vessels (p>0.05). Because of the altered mastectomy incisions, this study provides complete anatomical vascular properties and suggests that altering recipient vessel selection for bi-pedicled DIEP flaps can shorten anastomosis time and better conceal scars.

Postoperative Day 1 Discharge in Deep Inferior Epigastric Artery Perforator Flap Breast Reconstruction.

An institutional review board-approved, retrospective chart review of patients undergoing DIEP flap breast reconstruction from January 2019 to March 2022 at Atrium Health was completed, consisting of 510 patients and 846 DIEP flaps. Patient demographics, medical history, operative course, and postoperative complications were collected. Twenty-three patients totaling 33 DIEP flaps were discharged on POD1. The POD1 group and the group of all other patients (POD2+) had no difference in age, ASA score, or comorbidities. BMI was significantly lower in the POD1 group (P = 0.039). Overall operative time was significantly lower in the POD1 group, and this remained true when differentiating into unilateral operations (P = 0.023) and bilateral operations (P = 0.01). No major complications occurred in those discharged on POD1. POD1 discharge after DIEP flap breast reconstruction is safe for select patients. Lower BMI and shorter operative times may be predictive in identifying patients as candidates for earlier discharge.

An observational study of the impact of immediate breast reconstruction on perioperative inflammatory cytokines.

Perioperative inflammatory cytokines may be related to cancer proliferation, although few studies have investigated this issue in patients undergoing breast reconstruction surgery. We conducted a prospective study of patients scheduled for mastectomy only, mastectomy plus deep inferior epigastric perforator flap reconstruction (DIEP), or mastectomy plus tissue expander reconstruction (TE), with or without axial dissection (Ax), for primary breast cancer. Blood samples were collected for analysis of serum IL-6 and VEGF preoperatively, then within 24h postoperatively (POD 1), and 4-6days postoperatively (POD 4-6). We investigated the difference in serum cytokine levels over time for each surgical procedure and the difference in serum cytokine levels among the procedures at the three measurement time points. There were 120 patients included in the final analysis. Serum IL-6 was significantly higher than the preoperative level on POD 1 in patients who underwent mastectomy only, DIEP, or TE and Ax (+), with higher values persisting on POD 4-6 except in those who underwent DIEP. IL-6 was significantly higher after DIEP than after mastectomy only on POD 1, but no differences were observed at POD 4-6. VEGF did not differ significantly among the surgical procedures at any time. The increase in IL-6 was short term and immediate breast reconstruction is considered a safe procedure.

O036 Postoperative complications are predicted by surgery duration in the unilateral deep inferior epigastric perforator (DIEP) flap reconstruction: a retrospective cohort study

Abstract Introduction 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 and length-of-stay (LOS). Methods Electronic hospital data of adult women that underwent elective immediate or delayed unilateral DIEP reconstruction at a tertiary centre in London, between 2021 to 2022, was retrospectively analysed. Patients were divided into four groups depending on OT quartiles to define a critical cut-off period. Data on extensive potential confounders was recorded and used in univariable and multivariable regression models. Further statistical analyses were performed where appropriate. Results The final cohort contained 66 patients. Through quartiles, the risk-adjusted cut-off OT was defined as 515 minutes. After risk-adjustment, operations &amp;gt;515 minutes had a significantly higher overall complication rate than ≤515 minutes (HR: 2.16, p=0.032, 95% CI: 1.067, 4.38). No significant difference in mean ranks of LOS (p=0.16) was noted above the cut-off period. In patients that developed at least one complication type, no significant difference was observed in the unadjusted return-to-theatre rate between the two groups (HR: 0.86, p=0.82, 95% CI: 0.23, 3.24). Conclusion We confirmed OT was an independent predictor for postoperative complications in the DIEP flap and demonstrated this in unilateral reconstructions. Larger multicentre prospective studies are required to ascertain the significance of the OT effects, and to deduce the minimum OT threshold below which detriment to patient outcomes arises.

A Comparative Analysis of Sensory Return in Delayed-Immediate Versus Immediate Neurotized Deep Inferior Epigastric Perforator Flap Breast Reconstruction.

Breast reconstruction patients who anticipate adjuvant radiation are not suitable candidates for immediate deep inferior epigastric perforator (DIEP) flap reconstruction due to the risk of flap fibrosis, shrinkage, and fat necrosis. Rather, many of these patients undergo delayed-immediate, or "babysitter," reconstruction, where a tissue expander is placed first as a temporizing measure during adjuvant therapy before definitive flap reconstruction. In this study, we aim to compare sensory changes in delayed-immediate to immediate DIEP flap patients. Ninety-one patients, including 26 patients (46 breasts) with "babysitter" procedures and 65 patients (120 breasts) with immediate DIEP flaps, were prospectively identified at their preoperative visit. For both cohorts, baseline level (t = 0) is defined as before mastectomy. "Babysitter" patients underwent final-stage neurotized flap reconstruction on average at 12 months after initial tissue expander placement (range, 3-18 months). At 18 month after mastectomy (6 months after DIEP), delayed-immediate patients had comparable sensitivity measurements as immediate DIEP flap patients in all regions of the breast (P > 0.05). For delayed immediate patients, at 18 months postoperatively, sensitivity measurements were comparable with baseline levels only in the outer superior, outer medial, and outer lateral regions of the breast (P > 0.05). At 24 months postoperatively, cutaneous thresholds were comparable with baseline in all regions of the breast except the inner inferior region (P > 0.05), following a similar sensory recovery trajectory as immediate DIEP flap patients. In patients who undergo "babysitter" procedures, the combination of sensory return from the native mastectomy skin flap along with the neurotized DIEP flap yields sensory recovery comparable with immediate DIEP flap patients after definitive flap reconstruction. When final-stage flap reconstruction occurs by 12 months after mastectomy, sensation can return beginning 24 months postoperatively, or even sooner in some regions of the breast.

Replacing an Implant-Based with a DIEP Flap Breast Reconstruction: Breast Sensation and Quality of Life.

In this cohort study, the authors compared breast sensation and quality of life (QoL) after replacement of an implant-based breast reconstruction with a deep inferior epigastric perforator (DIEP) flap reconstruction in a singular sample of women. Women with implant-based breast reconstruction before their DIEP flap were included. Women formed their own control. Breast sensation was measured using Semmes-Weinstein monofilaments. QoL was evaluated using BREAST-Q questionnaires. Preoperative (T0) sensation and QoL were compared with postoperative values at 6 months (T1), at 12 months (T2), and at maximum follow-up (Tmax, sensation only). A linear mixed effects regression was used for Semmes-Weinstein monofilaments measurements; a paired samples t test was used for BREAST-Q scores. Most women chose replacement of their implant by a DIEP flap because of implant-related complaints. Postoperative sensation decreased significantly compared with preoperative sensation after T1 (mean, 5.1 months), T2 (mean, 14.6 months), and Tmax (mean, 17.6 months) for the total breast but recovers to preoperative levels for the native skin after an average of 1.5 years. Nerve coaptation positively influenced recovery of sensation. BREAST-Q scores increased significantly after 6 and 12 months over the domains Satisfaction with Breasts, Psychosocial Well-Being, Physical Well-Being of the Chest, and Sexual Well-Being. Scores decreased significantly in Physical Well-Being of the Abdomen after 6 months. Replacing an implant with a DIEP flap initially causes a decrease in overall breast sensation, gradually recovering to preoperative levels for native skin, and can significantly increase QoL with the right indication. Superior recovery of sensation and QoL may be obtained by accompanying the DIEP flap with nerve coaptation. Therapeutic, IV.

Impact of Intraoperative Hypothermia on Autologous Breast Reconstruction.

Studies have identified perioperative hypothermia as a risk factor for impaired wound healing, increased hospital length of stay, and surgical site infection. This study examines the effect of intraoperative hypothermia on postoperative outcomes in autologous microvascular free flap breast reconstruction. This was a retrospective review of 55 patients who experienced intraoperative hypothermia, defined as less than 35.0°C core body temperature and 99 normothermic patients who underwent autologous-based microvascular free flap breast reconstruction from 2013 to 2021. Demographics, comorbidities, smoking status, intraoperative warming devices, type of autologous reconstruction, hypothermia (and its duration), and length of surgery were collected. The outcomes assessed were infection rate, reoperation within 90 days, skin necrosis, wound healing complications, hematoma, seroma, and readmission within 90 days. In the study population of 154 consecutive patients, 8.4% had type 1 or type 2 diabetes and 3.2% were current smokers. A total of 90.3% of patients (139) underwent deep inferior epigastric perforator flap reconstruction, 7.1% (11) superficial inferior epigastric artery flap reconstruction, and 4 (2.6%) another free flap type. A total of 35.7% of the patients (55) experienced intraoperative hypothermia defined as less than 35.0°C. In the hypothermic group, a higher proportion of patients had wound healing complications (52.7% vs 29.3%, P < 0.05), hematoma (16.4% vs 5.1%, P < 0.05), and readmission for postoperative complications (34.5% vs 14.1%, P < 0.05). There was also a trend toward higher incidence of seroma (7.3% vs 5.1%), surgical site infection (12.7% vs 9.1%), skin necrosis (12.7% vs 9.1%), and unplanned reoperation within 90 days (10.9% vs 7.1%). Further analysis via Firth logistic regression demonstrated intraoperative hypothermia predicted postoperative hematoma (odds ratio [OR], 3.68; 95% confidence interval [CI], 1.17-11.60; P < 0.05), readmission within 90 days (OR, 3.20; 95% CI, 1.45-7.08; P < 0.05), and wound healing complications (OR, 2.69; 95% CI, 1.36-5.33; P < 0.05). This study demonstrates that intraoperative hypothermia is a significant risk factor for postoperative wound healing complications, hematoma, and readmission within 90 days in autologous breast reconstruction. Because of a finite amount of donor sites, it is important to find ways to minimize the risk of postoperative complications. Our results support that maintaining strict normothermia during autologous breast reconstruction can significantly improve patient outcomes and reduce morbidity.

Pre-operative Radiotherapy And Deep Inferior Epigastric Artery Perforator (DIEP) flAp study (PRADA): Aesthetic outcome and patient satisfaction at one year

The optimal combination of radiotherapy and breast reconstruction has not yet been defined. Post-mastectomy radiotherapy (PMRT) has deleterious effects on breast reconstruction, leading to caution amongst surgeons. Pre-operative radiotherapy (PRT) is a growing area of interest, is demonstrated to be safe, and spares autologous flaps from radiotherapy. This study evaluates the aesthetic outcome of PRT and deep inferior epigastric artery perforator (DIEP) flap reconstruction within the Pre-operative Radiotherapy And Deep Inferior Epigastric artery Perforator (DIEP) flAp (PRADA) cohort. PRADA was an observational cohort study designed to evaluate the feasibility and safety of PRT for women undergoing neoadjuvant chemotherapy and DIEP reconstruction. Panel evaluation of 3D surface images (3D-SIs) and patient-reported outcome measures (BREAST-Q) for a subset of women in the study were compared with those of a DIEP-PMRT cohort who had undergone DIEP reconstruction and PMRT. Seventeen out of 33 women from the PRADA study participated in this planned substudy. Twenty-eight women formed the DIEP-PMRT cohort (median follow-up 23 months). The median (inter-quartile range [IQR]) 'satisfaction with breasts' score at 12 months for the PRADA cohort was significantly better than the DIEP-PMRT cohort (77 [72-87] versus 64 [54-71], respectively), p=0.01). Median [IQR] panel evaluation (5-point scale) was also significantly better for the PRADA cohort than for the DIEP-PMRT cohort (4.3 [3.9-4.6] versus 3.6 [2.8-4] p=0.003). Aesthetic outcome for the PRADA cohort was reported to be 'good' or 'excellent' in 93% of cases using a bespoke panel assessment with robust methodology. Patient satisfaction at one year is encouraging and superior to DIEP-PMRT at 23 months. Switching surgery-radiotherapy sequencing leads to similar breast aesthetic outcomes and warrants further large-scale, multi-centre evaluation in a randomised trial.

Spotlight in Plastic Surgery: January 2023.

Spotlight in Plastic Surgery: January 2023.

Comparing Radiotherapy (RT) Late Toxicities to the Reconstructed DIEP Flap in Breast Cancer Patients Treated with Neoadjuvant RT (NART) vs. Post-Mastectomy RT (PMRT)

<h3>Purpose/Objective(s)</h3> The use of PMRT in patients undergoing immediate Deep Inferior Epigastric Perforator (DIEP) flap reconstructions is well known to cause significant long-term toxicity such as flap contracture, fat necrosis and cosmetic detriment. This can lead to significant long-term pain and impact on quality of life (QOL) (Yun et al, 2018). On the other hand, NART prior to the DIEP reconstruction performed in our institution has been shown to have no detriment in safety and local control but the long-term impact on the DIEP reconstruction remains unclear (Chidley et al, 2021). The aim of this retrospective study is to compare the long-term consequences of NART followed by DIEP versus immediate DIEP with PMRT on the reconstruction. <h3>Materials/Methods</h3> Retrospective comparison of long-term toxicities was done on the patient cohort who underwent NART followed by DIEP reconstruction (from 03/2013 to 09/2019) and patients who had immediate DIEP reconstruction followed by RT (from 01/2013 to 05/2021). Clinical examination was performed to assess the presence of fat necrosis (graded using the Wagner classification et al. 2013) and flap contracture. Breast cosmesis was graded using the Kroll classification (Kroll et al, 1994). Statistical analysis was performed to identify the rate of cosmesis problem, fat necrosis and flap contracture between these two patient's cohorts. <h3>Results</h3> Total of 155 patients who underwent NART and 31 patients who went through PMRT were analyzed. The median age of each cohort is 48 and 49 respectively for NART vs PMRT (p=0.26). Majority of patients in the NART and PMRT cohort received 50.4Gy/28# (78.6% [121] vs 74.2% [23]). Median follow up for NART and PMRT group was 32.5 months and 28.8 months respectively. No difference in local control was reported (98.1% NART vs 100% PMRT). Patients who had NART reported a higher satisfaction rating with their cosmesis. This was reported as ‘excellent to good' in 96.1% for NART compared to 80.1% for PMRT p<0.001. In addition, the risk of developing a flap contracture was significantly increased in patients who had PMRT (1.9% NART vs 41.9% PMRT; p<0.001). This was described as minimal in 29% and moderate in 12.9%. The risk of developing fat necrosis rate was also significantly increased in patients who had PMRT (12.9% NART vs 19.4% PMRT; p<0.001). While all fat necrosis in the NART cohort was grade 2, 50% of patients in the PMRT cohort had pain as well (grade 4). <h3>Conclusion</h3> Our retrospective analysis suggests that PMRT following immediate DIEP has significantly higher risk of late toxicities compared to NART followed by DIEP reconstruction. Whether this translates to a meaningful impact on QOL can only be determined by a randomized study.

Post Mastectomy Tissue Expander Placement followed by Radiation Therapy: A Cost-effectiveness Analysis of Staged Autologous vs. Implant-based Reconstruction

PURPOSE: There is no clearly preferred approach to breast reconstruction in patients with locally advanced breast cancer who require post-mastectomy radiation therapy (PMRT). Staged implant and deep inferior epigastric perforator (DIEP) flap reconstruction each have unique risks and benefits. No previous study compares the cost-effectiveness of these approaches with validated utility scores. METHOD: A literature review looking at prospective trials determined the probabilities and outcomes for mastectomy and staged implant reconstruction or staged DIEP flap reconstruction. Utility scores were used to calculate the quality adjusted life years (QALYs) associated with a successful procedure and post-operative complications. Medicare current procedure terminology and diagnosis-related group codes were used to assess the costs for a successful surgery and associated complications. A decision analysis tree was constructed with rollback analysis to highlight the more cost-effective strategy. An incremental cost-effectiveness ratio (ICER) analysis was performed with a willingness to pay at $50,000. Deterministic and probabilistic sensitivity analyses were performed to validate the robustness of the results, and to account for uncertainty in the data. RESULTS: Mastectomy with staged DIEP flap reconstruction is costlier ($14,104.80 versus $3,216.93), but more effective (29.96 versus 24.87) compared to staged implant reconstruction. This resulted in an ICER of 2141.00, which favored DIEP flap reconstruction, indicating a dominant strategy. In one-way sensitivity analysis, DIEP flap reconstruction was the more cost-effective strategy if the cost was less than $257,444.13. Monte Carlo analysis showed a confidence of 99.99% that DIEP flap reconstruction is more cost-effective. CONCLUSION: For patients with locally advanced breast cancer who require PMRT, mastectomy followed by staged DIEP flap reconstruction is significantly more cost-effective when compared with staged implant reconstruction. Despite the decreased morbidity, staged implant reconstruction has much greater rates of complication in irradiated fields including capsular contracture and infection.

Use of the Cephalic Vein in DIEP Breast Reconstruction Does Not Increase Risk of Lymphedema of the Ipsilateral Arm.

Flap failure is a rare but devastating complication in deep inferior epigastric perforator (DIEP) flap reconstructions. Common causes of partial or complete flap failure are related to venous congestion. Although the cephalic vein is usually a safe and reliable recipient vein for additional venous outflow, there is a hypothesized risk of donor-arm lymphedema secondary to lymphatic vessel damage in the vicinity of the cephalic vein or related to scarring and reduced venous backflow of the arm. The aim was to assess whether the cephalic vein as an additional recipient vessel, by means of the superficial inferior epigastric vein in DIEP flap breast reconstruction, was associated with long-term volume changes of the arm and/or symptoms of lymphedema. Arm volume was assessed preoperatively in patients scheduled to undergo unilateral delayed DIEP flap breast reconstruction at Uppsala University Hospital, Sweden, between 2001 and 2007. Long-term postoperative assessments were performed in 2015 to 2016. Water displacement and circumferential measurement were assessed preoperatively and postoperatively by the same lymphedema therapists. Patients were divided into two groups: DIEP reconstruction with the cephalic vein or without. Fifty-four patients fulfilled the inclusion criteria and completed the study, with a mean follow-up time of 136 months. There was no increased occurrence of lymphedema in the group undergoing DIEP flap reconstruction with the cephalic vein as extra venous drainage, based on an analysis of change from baseline in arm volume difference.This study shows that the cephalic vein can be used for secondary venous outflow in DIEP breast reconstruction without long-term risk of ipsilateral arm volume increase or symptoms of lymphedema. Risk, II.

Feasibility and Efficacy of Low Thoracic Ultrasound-Guided Erector Spinae Plane Blocks in Patients Undergoing Radical Total Mastectomy With Deep Inferior Epigastric Perforator Flap Reconstruction.

The analgesic efficacy of bilateral low thoracic erector spinae blocks for combined major breast and abdominal surgery has not been reported. The aim of this case series was to assess the feasibility and efficacy of T8 thoracic preincisional erector spinae blocks in patients undergoing total radical mastectomies with axillary lymph node dissections in addition to reconstruction with abdominal deep inferior epigastric flaps. The aim was to supply dermatomal coverage to provide analgesia for T2-L1 that formed the basis for an opioid-sparing multimodal technique in the context of our early recovery after breast surgery with deep inferior epigastric flap program.