Superficial Inferior Epigastric Artery Perforator Research Articles

Morbidity of the Donor Site and Complication Rates of Breast Reconstruction with Autologous Abdominal Flaps: A Systematic Review and Meta-Analysis

Background Numerous studies have evaluated the use of autologous abdominal tissue for breast reconstruction; nevertheless, complications and donor site morbidity rates vary significantly. The study aims to compare the literature regarding morbidity of the donor site and complication rates of breast reconstruction with autologous abdominal flaps. Methods The databases of MEDLINE, EBSCO, Scopus, Wiley Library, and Web of Sciences were searched for studies that compared different flaps in terms of complications and donor site morbidity. The procedures studied included pedicled transverse rectus abdominis myocutaneous flap (pTRAM), free TRAM (fTRAM), deep inferior epigastric perforator (DIEP), and superficial inferior epigastric artery perforator (SIEA) flaps. A total of 34 studies were included. Of these, 28 were retrospective studies and 9 were prospective cohort studies. Results When compared to DIEP, fTRAM flaps were found to have a decreased incidence of flap fat necrosis, hematoma, and total thrombotic events, yet a higher risk of donor site hernia/bulging. pTRAM flaps were also associated with an increased risk of hernia/bulging at the donor site, as well as wound infection, yet flap hematoma was less common. On the other hand, SIEA flaps showed the lowest risk of donor site hernia/bulging while still having a high risk of wound infection. Conclusion fTRAM procedures comparatively had the least complications. However, regarding flap choice, patients would benefit most from a case-by-case analysis, taking into consideration individual risk factors and preferences.

[The combination of anterolateral thigh perforator flap and other flaps for repairing the extreme circumferential defects on the limb].

To investigate the effectiveness of the combination of the anterolateral thigh perforator (ALTP) flap and other flaps for repairing the extreme circumferential defects on the limb. Between October 2016 and June 2019, 9 patients with the extreme circumferential defects on the limb were admitted, which resulted by degloving injury, including 8 males and 1 female with a median age of 42 years (range, 32-65 years). The etiology involved twist injury in 5 cases, traffic accident in 2 cases, and high voltage electric injury in 2 cases. The location of the defects was left forearm in 2 cases, right forearm in 3, left foot in 3, and right foot in 1. The injected wound bed followed by the exposure of bone, joint, tendon, and blood vessel. The dimension of defects was 25 cm×20 cm to 40 cm×28 cm. The period between the injury and admission was 1-12 hours (mean, 5 hours). All contaminated wounds were taken thorough and radical debridement and covered by the vacuum sealing drainage device during the emergency operation. The ALTP flap and the other one flap were tailored according to the dimension of the wound when the wound surface became granulating, including the thoracodorsal artery perforator (TAP) flap in 3 cases, superficial inferior epigastric artery perforator flap in 3 cases, superficial circumflex iliac artery perforator flap in 3 cases. And the donor site was primary closure. After operation, all the flaps survived except 1 case of partial necrosis at the edge of TAP flap and healed after secondary skin grafting, and the wounds in the donor and recipient areas healed by first intention. All patients were followed up 14-24 months (mean, 16 months). The shape of the flap was satisfactory and the texture was soft. There was no abnormal hair growth and obvious pigmentation during the follow-up. Only linear scar was left in the donor area, there was no complication such as abdominal wall hernia, and the activity of hip and knee was not affected. The functional reconstruction of upper limb and ankle was satisfactory, and the disabilities of the arm, shoulder, and hand (DASH) score was excellent in 4 cases and good in 1 case; the American Orthopaedic Foot and Ankle Association (AOFAS) score was excellent in 3 cases and good in 1 case. ALTP flap combined with different flaps can reconstruct the circumferential extreme defects after limb damage in one-stage, which can achieve limb salvage to the greatest extent.

ZNF667 attenuates leukocyte-endothelial adhesion via downregulation of P-selectin in skin flap following remote limb ischemic preconditioning.

We assessed the effects and potential mechanism of romote ischemic preconditioning (RIPC) on leukocytes-endothelium cell adhesion in the flap microvessel after ischemia-reperfusion (I/R) injury. Eight hours after reperfusion, edema and intravascular leukocyte aggregation were reduced and microvessels were more obvious in the group with superficial inferior epigastric artery (SIEA) perforator flap (SIEA-flap) subjected to RIPC than in the I/R group. Zinc finger protein 667 (ZNF667) was significantly increased but P-selectin was decreased in the flaps subjected to RIPC, compared to those in the I/R group. The low expression of P-selectin was associated with ZNF667 expression and activation in human dermal microvascular endothelial cells in response to hypoxic preconditioning. ZNF667 bound to the P-selectin promoter region, suppressing its transcription through a special core sequence. The ablation of P-selectin by small interfering RNA effectively prevented the leukocytes-endothelium cell adhesion effect of ZNF667-knockdown. ZNF667 upregulation attenuates leukocyte-endothelial cell adhesion by negatively regulating the expression of P-selectin in SIEA-flap subjected to RIPC.

Use of a combined SIEA and SCIP based double pedicled abdominal flap for breast reconstruction.

Recently, the deep inferior epigastric perforator (DIEP) flap has become the gold standard for breast reconstruction, but it has some drawbacks such as abdominal bulging and hernia. To overcome these disadvantages, the superficial inferior epigastric artery perforator (SIEA) flap is used as an alternative option, but it has another problem, namely limited vascular territory and risk of vascular thrombosis. To solve these problems, we introduced our new technique, a combined SIEA and superficial circumflex iliac artery perforator (SCIP) based double pedicled abdominal flap. In this report, we present our experience of using this technique. The SIEA and SCIP based double pedicled abdominal flap was used in five patients who wanted to have unilateral breast reconstruction after a mastectomy due to breast cancer. The average age was 48.2 (range 38-56) years, and the average BMI was 24.4 (range 19.2-31.4). The SIEA and SCIP based double pedicled abdominal flap was designed as a modified DIEP flap, and all flaps were placed in the vertical setting. The flap pedicles had two different vascular supplies, SIEA and SCIA, and the drainage systems, SIEV and SCIV, anastomosed to the internal mammary artery and vein in all cases. The harvested SIEA and SCIP based double pedicled abdominal flaps were a median volume of 925 g (range 452-1570 g) and average size of 491 cm2 (range 440-611 cm2 ). The average reconstructive time was 7:41 (range 6:31-9:17). In four out of the five cases, the SIEA and SCIA joined together to make a common pedicle artery trunk, and its average size was 1.08 mm. Four out of the five cases had a wide vascular territory crossing the abdominal midline as shown by ICG angiography. One case showed ICG fluorescence for the hemi-side of the abdominal flap. Postoperative course was uneventful, and there were no major perioperative complications, which need extra surgical procedures. Follow-up period averaged 273 days (range 194-312 days). The SIEA and SCIP based double pedicled abdominal flap showed viable flap territory across the midline in all cases. The SIEA and SCIP based double pedicled abdominal flap might be another ideal option for breast reconstruction, when appropriate SIEA and SCIA pedicles are identified, and an adequate ICG fluorescence is obtained for the size of flap needed.

[Application of contrast-enhanced ultrasound-assisted superficial inferior epigastric artery perforator flap to repair oral and maxillofacial defects].

To investigate the application value of contrast-enhanced ultrasound (CEUS) technique to assist the repair of oral and maxillofacial defects by superficial inferior epigastric artery perforator flap. Sixteen oral cancer patients, 10 males and 6 females, who were to undergo superficial inferior epigastric artery perforator flap repair between June 2018 and February 2020, were selected, with an average age of 55.8 years (range, 24-77 years). There were 13 cases of squamous cell carcinoma, 2 cases of adenoid cystic carcinoma, and 1 case of mucinous epidermis-like carcinoma. The color Doppler ultrasound (CDUS) and CEUS were used to screen the superficial inferior epigastric artery, assisted in the design of the flap, and compared it with the actual intraoperative exploration. The sensitivity, specificity, positive predictive value, and negative predictive value of CEUS and CDUS examinations were analyzed. Fourteen of 16 patients were repaired with superficial inferior epigastric artery perforator flap, and 2 patients were repaired with superficial iliac artery flap because the source artery was not found. After surgery, regular follow-up was performed to check for disease recurrence and metastasis and to evaluate the appearance of the patien's donor area, the recovery of transoral feeding function, and the presence of complications. Comparison of preoperative CDUS and CEUS findings and intraoperative exploration showed that CEUS had 100% sensitivity, specificity, positive predictive value, and negative predictive value for vascular exploration of the superficial inferior epigastric artery perforator flap, compared with 57%, 100%, 100%, and 25% for CDUS. The preoperative CDUS identified 25 penetrating vessels in 14 cases repaired with superficial inferior epigastric artery flaps. All vessel signals were enhanced by CEUS enhancement, and an additional 11 penetrating vessels were identified confirmed intraoperatively. The preoperative CEUS measurements of the initial diameter of superficial arteries in the abdominal wall were significantly higher than both CDUS and intraoperative measurements ( P<0.05); the difference in peak systolic velocity between CEUS and CDUS measurements was significant ( t=3.708, P=0.003). One case of superficial epigastric artery perforator flap developed venous embolism crisis at 48 hours after operation, the wound healing delayed. The other incisions in donor sites healed by first intention. All the patients were followed up 3-12 months, with an average of 8 months. No recurrence or metastasis appeared during the follow-up. There was no serious complications such as abdominal wall hernia, the location of abdominal scarring was hidden, and transoral feeding was resumed. The superficial inferior epigastric artery perforator flap with small injury in supply area and hidden scar location is a better choice for repairing oral and maxillofacial defects. The use of CEUS technique to assist the preoperative design of the superficial inferior epigastric artery perforator flap has good feasibility and high accuracy.

Thin superficial inferior epigastric artery perforator flap for reconstruction of the tongue.

The superficial inferior epigastric artery (SIEA) flap is widely used in the repair of large soft tissue defects of the extremities and in breast reconstruction. Because of the high fat content of the abdomen, it has been less used for glossectomy reconstruction. Here we present a series of seven patients who each underwent reconstruction with a thin SIEA flap after resection of the tongue. There were six men and one woman (mean age 48, range 24-66 years). All patients underwent preoperative computed tomographic (CT) angiography, and colour Doppler ultrasound (US) was used to select and map the most suitable SIEA. The flap was raised above the Scarpa's layer while adjusted the plane of dissection according to the specific needs for bulk in each case. All the flaps survived; one flap required a secondary anastomosis because of a venous anastomotic embolus. The size of flap used was 5.0cm×6.0cm - 7.0cm×9.0cm, and the flap was 0.8cm-1.4cm thick. The functional outcome was evaluated at 6 - 18 months follow up, when speech and swallowing were both good in all cases. The dissection above the pubic symphysis is an important refinement of the SIEA flap, and we conclude that the thin SIEA flap is a good choice for reconstruction after excision of cancer of the tongue.

“Three-dimensional evaluation of breast volume changes following autologous free flap breast reconstruction over six months”

ObjectivesTo date, little is known about postoperative changes in breast volume after autologous breast reconstruction. The purpose of this retrospective study was to investigate breast volume changes following autologous free flap reconstruction and the factors affecting flap volume. Materials and methodsPatients who underwent deep inferior epigastric perforator, superficial inferior epigastric artery and profunda artery perforator flaps between December 2016 and January 2019 were included. Exclusion criteria were breast complications requiring surgical debridement, and the absence of at least two suitable three-dimensional images postoperatively. Three-dimensional stereophotogrammetry volume measurements were performed at the time of standard surgical check-ups. Changes in breast volume were modeled using a quartic polynomial curve function in a nested mixed effects model. Results136 breasts in 101 patients were included. An average decrease of predicted breast volume was found from 637.8 cc (95%-CI [624.4, 651.1]) at two weeks to 566.6 cc (95%-CI [535.1, 598.0]) after three and 567.6 cc (95%-CI [515.9, 617.6]) after six months postoperatively. Reconstruction timing and first postoperatively measured breast volume showed a statistically significant difference in initial reconstructed breast volume and in the shape of the relationship between time and breast volume, whereas autologous technique and BMI only showed a statistically significant difference in initial reconstructed volume and mastectomy indication in the shape of the relationship. ConclusionThe final overall flap volume decreased to 88.9% of its original volume after six months. Gaining more insight into the factors influencing flap volume is of crucial importance to facilitate predictable surgical outcomes.

Immediate Bilateral Breast Reconstruction Using Abdominally Based Flaps: An Analysis of the Nationwide Inpatient Sample Database.

Bilateral mastectomy rates are increasing in the United States. The abdomen is the most common harvest site for autologous reconstruction. Nationwide data were examined to determine differences in hospital charges, length of stay (LOS), and early postoperative complications following immediate bilateral pedicled transverse rectus abdominis myocutaneous (pTRAM), free TRAM (fTRAM), deep inferior epigastric perforator (DIEP), and superficial inferior epigastric artery (SIEA) perforator flaps and were compared with unilateral reconstruction. Patients who underwent immediate bilateral breast reconstruction using a single method of abdominally based reconstruction were identified using the 2009 to 2014 Nationwide Inpatient Sample Database. Outcomes included total hospital charges, LOS, and immediate postoperative complications. We identified 13,348 cases of bilateral mastectomy with a single type of immediate bilateral autologous flap reconstruction. The majority were bilateral DIEP flaps. Mean total cost for bilateral pTRAM, fTRAM, DIEP, and SIEA flaps was US $21,886.80, US $28,839.40, US $30,051.30, and US $33,784.90, respectively (p < 0.0001). Mean LOS for bilateral pTRAM, fTRAM, DIEP, and SIEA was 4.3, 4.9, 4.5, and 5.4 days, respectively (p = 0.0002), and hematoma rates were 1.93, 2.61, 3.68, and 16.59%, respectively, (p = 0.0001), whereas return to the operating room for vascular anastomosis revision was 0, 1.63, 1.99, and 19.07%, respectively (p < 0.0001). Cost is less for unilateral pTRAM, fTRAM, and DIEP flaps (p < 0.0001). LOS is shorter for unilateral fTRAM versus bilateral (p < 0.0001). No differences were appreciated between unilateral and bilateral hematoma and reoperation rates for any reconstruction (p > 0.1). Immediate complication rates were higher in bilateral free flaps compared with bilateral pedicled flaps. pTRAM and fTRAM flap reconstructions are still performed frequently with acceptable immediate results without considering long-term morbidity, aesthetics, and abdominal muscle function. Bilateral SIEA free flaps were associated with significantly higher total cost, LOS, and complication rates compared with other groups. Complications were similar between unilateral and bilateral reconstruction procedures. While cost is significantly greater for bilateral procedures compared with unilateral pTRAM, fTRAM, and DIEP flaps, it is not doubled.

The Deep Circumflex Iliac Artery Perforator Flap for Breast Reconstruction: Un lambeau perforateur de l'artère iliaque circonflexe profonde pour la reconstruction mammaire.

Autologous breast reconstruction using abdominal-based perforator flaps produces excellent aesthetic results with minimal donor site morbidity. The superficial inferior epigastric artery and deep inferior epigastric perforator (DIEP) flaps reliably perfuse a hemi-abdomen, up to the anterior axillary line. Beyond this line laterally, the flank or "love handle" tissue is primarily perfused by the deep circumflex iliac artery (DCIA) or secondarily by the superficial circumflex iliac artery. The flank tissue is a valuable addition to increase flap size when harvested with a DIEP flap or to provide vascularized tissue when the abdomen has been previously harvested. Harvesting the flank tissue in combination with the anterior abdominal tissue improves the contour of the trunk, accentuates the waist, and minimizes secondary revisions to excise prominent "dogears." The DCIA flap is a novel technique for breast reconstruction. In this article, we describe our technique, pearls and pitfalls, and early results.

Immediate Unilateral Breast Reconstruction using Abdominally Based Flaps: Analysis of 3,310 Cases.

The abdomen is the most common area from which tissue is harvested for autologous breast reconstruction. We sought to examine national data to determine the differences in total hospital charges, length of stay (LOS), and early postoperative complications following pedicled transverse rectus abdominis myocutaneous flap (pTRAM), free TRAM (fTRAM), deep-inferior epigastric perforator (DIEP), and superficial inferior epigastric artery perforator (SIEA) flaps. The 2009-2013 Nationwide Inpatient Sample Database was used to identify patients who underwent a unilateral mastectomy and only one type of abdominally based autologous flap (pTRAM, fTRAM, DIEP, and SIEA) during the same hospital admission. Outcomes of interest included total charges, LOS, and complications including revision of vascular anastomosis and hematoma. A total of 3,310 cases were identified, corresponding to 15,991 abdominally based unilateral immediate breast reconstructions after standard weighting was applied; 5,079 (31.8%) were pTRAM flaps, 4,461 (27.9%) were fTRAM flaps, 6,206 (38.8%) were DIEP flaps, and 245 (1.5%) were SIEA flaps. The mean total charges for pTRAM, fTRAM, DIEP, and SIEA flaps were $17,765.5, $22,637.6, $25,814.6, and $26,605.2, respectively (p < 0.0001). The mean LOS for pTRAM, fTRAM, DIEP, and SIEA flaps were 96.5, 106.5, 106.7, and 108.9 hours, respectively (p = 0.002). The rates for return to the OR for the revision of a vascular anastomosis for pTRAM, fTRAM, DIEP, and SIEA were 0.0%, 1.72%, 2.66%, and 5.64%, respectively (p < 0.0001). There is variation in the total charges, LOS, and early complications between pTRAM, fTRAM, DIEP, and SIEA flap-based breast reconstruction. fTRAM, DIEP, and SIEA flaps incur higher hospital total charges, have longer lengths of stay, and experience more immediate complications compared with pTRAM. Well-designed prospective trials are required to better understand the findings from this study with the inclusion of other critical outcomes such as patient satisfaction, aesthetic results, and long-term outcomes such as abdominal wall morbidity.

Anatomy of superficial inferior epigastric vessels: revival of superficial inferior epigastric (SIEA) flap

Development of perforator flaps evolves the perspective of reconstructive surgery to another level due to many of their advantages over the pedicled flaps, particularly lower donor-site morbidity and versatility in flap design. Superficial inferior epigastric artery (SIEA) flap offers this significant advantage over other lower abdominal flaps, as dissection of the rectus abdominis muscle is not required. However, both vascular agenesis and inappropriate vessel size for anastomosis are the major limitations. This study was therefore aimed to investigate these aspects of this flap. Twenty cadavers were dissected bilaterally to demonstrate vascular anatomy of these vessels. The SIEA of each cadaver was dissected and traced from the origin (femoral arteries) to their presence in the subcutaneous layer. Originating patterns of these vessels, whether sharing a common trunk with other vessels such as superficial circumflex iliac (SCI) or superficial external pudendal (SEP) arteries, was determined and their diameters measured. SIEA agenesis rate was found to be 7.5% (3/40). The diameters greater than 1 and 1.5 mm were found in 86% (32/37) and 30% (11/37), respectively. The distance between its origin and point of entering Scarpa’s fascia varies from 10.29 to 62.62 mm (mean 37.48 mm). As opposed to the artery, the superficial inferior epigastric vein was found to be present in all dissections with a diameter ranging from 2.12 to 5 mm (mean 3.09 mm) and the distance, as measured in SIEA, ranging from 20.1 to 74.28 mm (mean 41.24 mm). SIEA usually crosses the inguinal ligament within area between mid-inguinal point and 3 cm medially. Correlations were found (1) between SIEA diameter and pedicle length and (2) between bilateral pedicle lengths of both artery and vein. The high prevalence of both SIEA presence and appropriate diameter for anastomosis, and thus flap success, makes the SIEA perforator flap an appropriate option for reconstructive treatment. Level of Evidence: not ratable.

Non-Invasive Imaging of Preoperative Mapping of Superficial Veins in Free Flap Breast Reconstruction.

Vascular anatomy is imperative in reconstructive surgery to ensure perfusion and accurate flap design, but venous anatomy can be difficult to determine preoperatively. Anatomic landmarks can be used to locate structures; however there can be considerable variation in anatomy and location of veins. Techniques such as radiographic imaging, Doppler probes, and ultrasonography have been used to assess veins. However, radiographic imaging incurs a cost and radiation exposure. Doppler probes are easy to use but are more useful for arterial anatomy. Ultrasonography is limited by cost, time, and accessibility. Several vein visualization devices, including the AccuVein (Avant Medical, Cold Spring Harbor, NY, USA), have been previously reported as an adjuvant to locate veins [1] and to aid intravenous cannulation. These devices were helpful to visualize veins, especially in difficult patients (extremes of age, obese, dark-skinned) [2,3,4]. The AccuVein is a portable device (size, 5×6×20 cm; weight, 275 g) that emits a red laser at 642 nm and an infrared laser at 785 nm. Hemoglobin preferentially absorbs infrared light so the skin the skin illuminated a red color and veins are silhouetted as dark outlines (Fig. 1). The color schemes can also be inverted to display veins as red silhouettes on the skin. Fig. 1 (A, B) Hand-held vein visualization device, (AccuVein) uses a red laser and infrared laser to illuminate basilic and cephalic venous vasculature for the forearm. The AccuVein device was used in our study for abdominal-based free flap breast reconstruction to aid in locating abdominal veins and to evaluate candidacy for superficial inferior epigastric artery (SIEA) perforator flaps. To the best of our knowledge the use of this device in breast reconstruction has not been reported. The current practice at our institution for planned free flap breast reconstruction involves intraoperative decision-making to determine flap type [5]. Routine preoperative radiographic imaging is not obtained. After making the inferior incision on the abdomen the SIEA is carefully identified. If the SIEA is absent, injured, or of insufficient caliber (<1.5 mm) then an SIEA flap is not used and the deep inferior epigastric system is assessed next. Medial and lateral row perforators are identified and a decision is then made to use either a deep inferior epigastric artery perforator flap or a muscle-sparing free transverse rectus abdominis musculocutaneous flap [5]. In our study the AccuVein was used for preoperative venous mapping of the superficial inferior epigastric veins (SIEV), superficial circumflex iliac veins, and to help guide dissection and flap design of the inferior skin paddle incision (Fig. 2). If an adequate SIEV was visualized preoperatively, the inferior skin incision was occasionally redesigned and made more inferior to ensure inclusion of the vascular pedicle before it arborizes. Fig. 2 Preoperative visualization of left superficial epigastric vein before breast reconstruction. The AccuVein was used on ten patients. In eight patients at least one SIEV was identified preoperatively in all patients and there was 100% positive and negative correlation of preoperative markings with intraoperative exploration (Fig. 3), and all veins were able to be identified intraoperatively. In the other two patients had abdominal striae that interfered with venous imaging and abdominal veins were not able to be visualized. In two patients preoperative vein mapping changed the flap design: the inferior incision was lowered to explore the vein before it bifurcates to include a larger caliber vessel in the flap for flap drainage or when patients were possible SIEA flap candidates. There were no AccuVein related complications and no false negatives that led to adverse flap planning. There were also no other perioperative complications or microvascular complications or flap losses for all ten patients and patients were on average, discharged on postoperative day 4.1 (range, 4–5). Fig. 3 (A, B) Preoperative and intraoperative photographs of superficial epigastric vein during the donor site dissection of abdonimal-based free flap breast reconstruction using right hemi-abdomen. The AccuVein is a non-invasive, portable, fast, and easy to use device to assess veins in real time. The disadvantages of this device are that it only produces a two dimensional image and the vein is displayed based on vessel content and not the actual vessel caliber. Although there were no false positives in our study, we recommend direct visualization of vessel caliber before any surgical decisions are made. The AccuVein can provide preoperative information about venous anatomy that can be useful in aiding dissecting veins and flap design. The AccuVein is not necessary to successfully perform free flap breast reconstruction but we believe the AccuVein is an effective adjuvant that can help aid flap design and expedite dissection. The SIEV is a useful lifeboat that can be used as venous outflow for abdominal-based flaps and also used as a vein graft. Anatomic landmarks exist for most critical structures, and the SIEV is also consistently found midway between the anterior superior iliac spine and the midline. But anatomy can be variable and the AccuVein can expedite dissection and flap design. Preoperative vein mapping can be useful for those starting to perform SIEA perforator breast free flap reconstructions. Preoperative venous mapping can help guide flap design and speed dissection of the SIEV and SIEA vena comitans. Radiographic imaging provide much more information than can AccuVein, but also costs more, is invasive if contrast-enhanced imaging is used, may require radiation exposure, and needs time to schedule, perform, and review images. On the other hand, the AccuVein device is often already available in many hospitals in the nursing units and is a simple, cheap, noninvasive, and quick method for preoperative mapping of superficial veins.

Comprehensive Evaluation of Risk Factors and Management of Impending Flap Loss in 2138 Breast Free Flaps.

Loss of a breast free flap is a relatively rare but catastrophic occurrence. Our study aims to identify risk factors for flap loss and to assess whether different salvage techniques affect flap salvage. We performed a retrospective review of all breast free flaps performed at a single institution from 2000 to 2010. Overall, 2138 flaps were performed in 1608 patients (unilateral, 1120 and bilateral, 488) with 44 flap losses (2.1%). Age, body mass index, smoking, radiation, chemotherapy, and surgeon experience did not affect flap loss. Abdominal flaps based on a single perforator were at significantly higher risk for flap loss compared with flaps based on multiple perforators (P = 0.0007). Subgroup analysis of the subset of 166 compromised free flaps (flaps requiring a return to the operating room, an intraoperative anastomotic revision, or loss/partial loss of a free flap) demonstrated deep inferior epigastric perforator, and other flaps (superficial inferior epigastric artery and superior gluteal artery perforator) were significantly associated with flap loss [odds ratio (OR) 5.20; P = 0.03 and OR 6.91; P = 0.0004, respectively] compared with transverse rectus abdominis myocutaneous and muscle-sparing transverse rectus abdominis myocutaneous flaps. Although an intraoperative complication was not associated with a flap loss, the need for a reoperation was strongly predictive (P < 0.0001). Flap salvage was the highest within the first 24 hours (83.7%) and significantly less between days 1 and 3 (38.6%; P < 0.0001) and beyond 4 days (29.4%; P < 0.0001). Longer ischemia time was significantly associated with flap loss (P = 0.04). Salvage techniques (aspirin, heparinzation, thrombectomy, and thrombolytic) had no impact on flap salvage rates. Heparinization and thrombolytics were associated with higher loss rates (OR 3.40; P = 0.003 and OR 10.36; P < 0.0001, respectively). Free flap loss following breast reconstruction is multifactorial with higher losses in superficial inferior epigastric artery and gluteal flaps, single-perforator abdominal flaps, and longer ischemia times. Salvage rates are most successful within the first 24 hours, and the use of heparinization, aspirin, and thrombolytics does not improve salvage rates.

Funding analysis of bilateral autologous free-flap breast reconstructions in Australia

Bilateral breast reconstructions are being increasingly performed. Autologous free-flap reconstructions represent the gold standard for post-mastectomy breast reconstruction but are resource intensive. This study aims to investigate the difference between hospital reimbursement and true cost of bilateral autologous free-flap reconstructions. Retrospective analysis of patients who underwent bilateral autologous free-flap reconstructions at a single Australian tertiary referral centre was performed. Hospital reimbursement was determined from coding analysis. A true cost analysis was also performed. Comparisons were made considering the effect of timing, indication and complications of the procedure. Forty-six bilateral autologous free-flap procedures were performed (87 deep inferior epigastric perforators (DIEPs), four superficial inferior epigastric artery perforator flaps (SIEAs) and one muscle-sparing free transverse rectus abdominis myocutaneous flap (MS-TRAM)). The mean funding discrepancy between hospital reimbursement and actual cost was $12,137 ± $8539 (mean ± standard deviation (SD)) (n = 46). Twenty-four per cent (n = 11) of the cases had been coded inaccurately. If these cases were excluded from analysis, the mean funding discrepancy per case was $9168 ± $7453 (n = 35). Minor and major complications significantly increased the true cost and funding discrepancy (p = 0.02). Bilateral free-flap breast reconstructions performed in Australian public hospitals result in a funding discrepancy. Failure to be economically viable threatens the provision of this procedure in the public system. Plastic surgeons and hospital managers need to adopt measures in order to make these gold-standard procedures cost neutral.

The Evolution of Perforator Flap Breast Reconstruction: Twenty Years after the First DIEP Flap

It is over 20 years since the inaugural deep inferior epigastric perforator (DIEP) flap breast reconstruction. We review the type of flap utilized and indications in 2,850 microvascular breast reconstruction over the subsequent 20 years in the senior author's practice (Robert J. Allen). Data were extracted from a personal logbook of all microsurgical free flap breast reconstructions performed between August 1992 and August 2012. Indication for surgery; mastectomy pattern in primary reconstruction; flap type, whether unilateral or bilateral; recipient vessels; and adjunctive procedures were recorded. The DIEP was the most commonly performed flap (66%), followed by the superior gluteal artery perforator flap (12%), superficial inferior epigastric artery perforator flap (9%), inferior gluteal artery perforator flap (6%), profunda artery perforator flap (3%), and transverse upper gracilis flap (3%). Primary reconstruction accounted for 1,430 flaps (50%), secondary 992 (35%), and tertiary 425 (15%). As simultaneous bilateral reconstructions, 59% flaps were performed. With each flap, there typically ensues a period of enthusiasm which translated into surge in flap numbers. However, each flap has its own nuances and characteristics that influence patient and physician choice. Of note, each newly introduced flap, either buttock or thigh, results in a sharp decline in its predecessor. In this practice, the DIEP flap has remained the first choice in autologous breast reconstruction.

Analysis of the Deep and Superficial Inferior Epigastric Arteries Using Computed Tomographic Angiography

INTRODUCTION: Preoperative CT angiography (CTA) can be used for surgical planning for breast reconstruction utilizing free tissue transfer from the abdomen. Recent studies support a correlation between CTA and intraoperative vascular findings resulting in efficient and predictable operations and a higher chance of using flaps that maintain abdominal wall integrity such as superficial inferior epigastric artery (SIEA) or deep inferior epigastric artery (DIEA) perforator flaps.1 We report an anatomical study of the course and caliber of the DIEA and SIEA in a cohort of women, including the relationship of perforator caliber to abdominal wall anatomy. METHODS: Radiology records from January 2007 to May 2012 were searched. One-hundred four patients who underwent preoperative CTA were identified. Measurements included: SIEA and SIEV’s distance from midline and arterial caliber, DIEA entry into the rectus muscle, caliber at takeoff from the external iliac artery, perforator caliber, site of entry at the rectus sheath, and abdominal wall thickness (AWT). Locations were recorded as x and y coordinates relative to the umbilicus (x axis) and the pubic symphysis (y axis). Statistical comparisons were made between perforator size and AWT, BMI, and number of perforators within each hemi-abdomen. RESULTS: The SIEA was visualized unilaterally in 19 patients and bilaterally in 14 patients. The SIEA was on average 6.8±1.1 cm from midline and 25% of ASIS to ASIS and 1.4 mm in diameter proximally. The SIEV was on average 6±1.3 cm from midline and 22% of ASIS to ASIS. Most large caliber perforators (>2mm) were within a 6 cm radius of the umbilicus. Number of perforators per hemi-abdomen inversely correlated with mean arterial diameter (single perforator, 19±0.1 mm vs four perforators, 17±0.1 mm, p=0.03) as well as AWT and BMI (Figures 1 and 2).Figure 1: Right DIEA entry.Figure 2: Left DIEA entry.CONCLUSION: This study adds insight to the anatomic configuration of the abdominal circulation, and the novel finding of the inverse relationship between number and caliber of perforators to AWT and BMI. The caliber and course of the vessels are predictable and related to number of perforators and abdominal girth. This may offer insight to the increased rate of ischemic-based complications including fat necrosis in patients with elevated AWT.

SIEA flap leads to an increase in abdominal seroma rates compared to DIEP flap for breast reconstruction

In this study, we evaluated the peri-operative abdominal drain volumes and length of hospital admission between our superficial inferior epigastric artery (SIEA) and deep inferior epigastric artery perforator (DIEP) patients to determine whether SIEA flaps were associated with increased post-operative abdominal drainage and length of hospital stay. We studied consecutive patients who had breast reconstruction using either a free SIEA (seven) or DIEP (28) flaps. All patients had abdominal drains inserted, and cumulative drainage measurements were taken every 24 h. Data on patient's age, BMI, length of hospital stay, smoking history, and abdominal fluid drainage were collected. Statistical analyses were performed using a t test (Mann–Whitney). A statistically significant difference (P = 0.029) was observed in the total abdominal drainage between the two groups. The mean drainage volume in the SIEA group was 2,248 ml and 531 ml in the DIEP group. No association was observed between smoking and drainage volume in the DIEP group. Similarly, obesity did not appear to influence drainage volumes in either the SIEA or the DIEP groups. The average length of stay for the SIEA group was 10.4 days and 9.1 days in the DIEP group, although this was not statistically significant (P = 0.351). While abdominal wall morbidity is reduced in patients undergoing an SIEA flap for breast reconstruction, in our series, we found that the SIEA flap was associated with a significant increase in abdominal drain volume relative to the DIEP flap, which translated to an extra day in hospital.

A Comparison of the Superficial Inferior Epigastric Artery Flap and Deep Inferior Epigastric Perforator Flap in Postmastectomy Reconstruction: A Cost-Effectiveness Analysis

To perform a cost-effectiveness analysis comparing the superficial inferior epigastric artery (SIEA) and deep inferior epigastric perforator (DIEP) flaps in postmastectomy reconstruction. A decision analytic model with seven clinically important health outcomes (health states) was used, incorporating the Ontario Ministry of Health's perspective. Direct medical costs were estimated from a university-based hospital. The utilities of each health state converted into quality-adjusted life years (QALYs) were obtained from previously published data. Health state probabilities were computed from a systematic literature review. Analyses yielded SIEA and DIEP expected costs and QALYs allowing calculation of the incremental cost-utility ratio (ICUR). One-way sensitivity analyses were conducted under five plausible scenarios, assessing result robustness. Five SIEA and 27 DIEP studies were identified. The baseline SIEA expected cost was slightly higher than that for the DIEP ($16,107 versus $16,095), with slightly higher QALYs (33.14 years versus 32.98 years), giving an ICUR of $77/QALY. Taking into account conversions from SIEA to DIEP, the ICUR increased to $4,480/QALY. Sensitivity analysis gave ICURs ranging from $2,614/QALY to 'dominant', all consistent with the adoption of the SIEA over the DIEP. The best available evidence suggests the SIEA is a cost-effective procedure. However, given the high SIEA to DIEP conversion rates and small marginal differences in cost and effectiveness, the ICUR may be sensitive to minor changes in costs or QALYs. The 'truth' can only be obtained from a randomized, controlled trial comparing both techniques side by side, simultaneously capturing the costs of the competing interventions.

The Cutaneous Arteries of the Anterior Abdominal Wall: A Three-Dimensional Study

Sir: We congratulate Tregaskiss et al. for their study utilizing computed tomography angiography in the evaluation of the abdominal wall vasculature.1 As mentioned in their article, computed tomography angiography has only recently been suggested for preoperative imaging before use of superficial inferior epigastric artery (SIEA) and deep inferior epigastric artery (DIEA) perforator flaps, but it has yet to be adequately evaluated for this purpose. Their article, “The Cutaneous Arteries of the Anterior Abdominal Wall: A Three-Dimensional Study,” certainly contributes to the literature on this topic. We would like to share our work on this topic, which we believe may shed more light on this rapidly advancing field of anatomical research, in light of their article. We have undertaken a study of 10 cadaveric hemiabdominal walls, which is currently in the submission process for this Journal, in which we performed isolated DIEA contrast injection in each case. Our injection technique and harvesting methods were done in a fashion similar to that of Tregaskiss et al., and our specimens underwent computed tomography scanning in a similar way. Our computed tomography scanner differed in that it was a 64 multidetector row scanner, which permits a greater number of slices and greater resolution of images. Our reformatting also differed, in that we created maximum intensity projection images in addition to three-dimensional volume-rendered technique images. In general, our findings confirm the findings of Tregaskiss et al., in that computed tomography was able to effectively demonstrate the SIEA system, the cutaneous branches of the SIEA system, the musculocutaneous perforators, and the DIEA system. Of note, we were able to identify both SIEAs in 80 percent of patients, compared with 40 percent in the study by Tregaskiss et al. These data, however, do not achieve a formal evaluation of the use of computed tomography angiography. In an attempt to achieve this, we performed post–computed tomography dissection of all the musculocutaneous perforators in each specimen (total number on computed tomography angiography = 154 perforators), which enabled us to evaluate the use of computed tomography angiography for perforator mapping, as both a tool for demonstrating cadaveric anatomy and a potential tool for preoperative imaging before use of DIEA perforator flaps.2–4 We found that the DIEA system demonstrated on computed tomography angiography, including the course of the DIEA and its branching pattern,5 was 100 percent concordant with dissection findings in all cases (Fig. 1). Similarly, the mapping of musculocutaneous perforators was highly accurate, with only eight false-positive results and six false-negative results out of 154 perforators seen on computed tomography angiography, revealing a sensitivity of 96 percent and a specificity of 95 percent for the mapping of musculocutaneous perforators of the DIEA (Fig. 2).Fig. 1.: (Left) Computed tomography angiogram with volume-rendered technique image of the DIEA system in a cadaveric abdominal wall. (Right) Dissection findings demonstrating concordance with computed tomography findings.Fig. 2.: (Left) Computed tomography angiogram with volume-rendered technique image of the musculocutaneous perforators at the level of perforating the anterior rectus sheath in a cadaveric abdominal wall. (Right) Dissection findings demonstrating concordance with computed tomography findings. In the computed tomography image, intramuscular vessels are green and cutaneous vessels are red (green arrows, perforators; pink arrow, umbilicus).Our study demonstrates that computed tomography angiography can be used with high accuracy in anatomical studies such as that of Tregaskiss et al., and suggests that this may be an ongoing modality for imaging vasculature in both anatomical studies and preoperative imaging. This type of anatomic cadaveric study does not necessarily reflect the accuracy of computed tomography angiography in the clinical setting, where it is used preoperatively to localize DIEA perforators before DIEA perforator flap surgery. Further work in this area is required to establish the role and accuracy of computed tomography angiography in DIEA perforator flap planning. Warren M. Rozen, M.B.B.S. Jack Brockhoff Reconstructive Plastic Surgery Research Unit University of Melbourne Damien L. Stella, F.R.A.N.Z.C.R. Department of Radiology Royal Melbourne Hospital Mark W. Ashton, F.R.A.C.S. Jack Brockhoff Reconstructive Plastic Surgery Research Unit University of Melbourne Timothy J. Phillips, M.B.B.S. Department of Radiology Royal Melbourne Hospital G. Ian Taylor, F.R.C.S., F.R.A.C.S. Jack Brockhoff Reconstructive Plastic Surgery Research Unit University of Melbourne Parkville, Victoria, Australia DISCLOSURE The authors declare that there is no source of financial or other support or any financial or professional relationships that may pose a competing interest.

Breast Reconstruction Using the Entire Transverse Abdominal Adipocutaneous Flap Based on Unilateral Superficial or Deep Inferior Epigastric Vessels

Among various alternatives for autologous breast reconstruction, the superficial inferior epigastric artery abdominal flap provides the least donor-site morbidity, as dissection of the rectus abdominis sheath and muscle is not required. However, because of inconsistencies in the existence and size of the superficial inferior epigastric artery, its use is limited. In addition, whether the perfusion from the superficial system is adequate across the midline is still a question to be answered. Over a period of 16 months, the authors performed a total of 44 breast reconstructions using either the deep inferior epigastric artery perforator flap (n = 30) or the superficial inferior epigastric artery flap (n = 14). In all cases, the superficial inferior epigastric artery system was explored first and used as the pedicle if the diameter of the available vessels was larger than 1 mm. If the vessels were unavailable or the diameters were smaller than 1 mm, the deep inferior epigastric artery and vein were used as the pedicle. The diameter of the superficial inferior epigastric artery ranged between 0.8 and 3.0 mm, and the mean pedicle length was 6 cm. The superficial inferior epigastric artery was not available in 21 cases (48 percent), and in nine cases (20 percent) the diameter was smaller than 1 mm. In six cases where the superficial inferior epigastric artery was judged to be appropriate, laser Doppler study was performed perioperatively to assess the perfusion of each zone (I through IV) from the deep and superficial systems consecutively. In all cases, the superficial and deep systems ipsilateral to the defect were dissected. During inset, zone IV was not discarded routinely, and 92.3 percent and 86.7 percent of the harvested superficial inferior epigastric artery flap and deep inferior epigastric artery perforator flap, respectively, were used. The flap survival rates were 93 and 100 percent in the superficial inferior epigastric artery and deep inferior epigastric artery perforator groups, respectively. Adequate perfusion of all zones from the superficial system was documented by laser Doppler flowmetry, and the perfusion rates were comparable to the deep system. The entire abdominal adipocutaneous flap based on the unilateral superficial inferior epigastric artery is as reliable as one based on the deep inferior epigastric artery perforator flap. As a result, initially, the superficial inferior epigastric artery flap should be explored, as it provides less donor-site morbidity. A sizable superficial artery and vein is sufficiently safe for microsurgical transfer, similar to the deep inferior epigastric system.