Increase of major complications with a longer ischemia time in breast reconstruction with a free deep inferior epigastric perforator (DIEP) flap

Abstract Background The deep inferior epigastric artery perforator (DIEP) flap is one of the most used free flaps for postmastectomy breast reconstruction. Prolonged ischemia can result in (partial) flap loss. The aim of this study was to evaluate the association between ischemia time and postoperative complications of DIEP flap breast reconstruction. Methods A retrospective study of all patients who received a breast reconstructionwith aDIEP flap atMaastricht University Medical Center in theNetherlands, between January 2010 and June 2017 (n = 677). The flaps were divided into two groups: flaps with an ischemia time less than 60 min and those with 60 min or more. Recipient site complications, in particular major complications equal to re-exploration, and partial or total flap loss were the primary outcome measures. Results In 23.9% of the 677 included DIEP flaps, the ischemia time was 60 min or longer. Within this group, a complication of the recipient site occurred in 30.9% of the flaps. A major complication occurred in 17.3% of the flaps with 60 min or more ischemia time.With regard to the flaps with less than 60-min ischemia time, a complication occurred in 22.1% of the cases of which 8.9%would be considered amajor complication. A significant association was found between ischemia time and major complications on univariate (p value = 0.003) and multivariate analyses (p value = 0.016). Conclusions This study demonstrates that an ischemia time less than 60 min is associated with a significantly lower risk of major recipient site complications compared to an ischemia time of 60 min or more. Level of evidence: Level III, therapeutic, risk/prognostic study.

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Exploring personalized postoperative non-invasive tissue oximetry in DIEP flap breast reconstruction

European Journal of Plastic Surgery ◽

10.1007/s00238-021-01873-7 ◽

2021 ◽

Author(s):

Anouk A. M. A. Lindelauf ◽

Nousjka P. A. Vranken ◽

Rutger M. Schols ◽

Esther A. C. Bouman ◽

Patrick W. Weerwind ◽

...

Keyword(s):

Early Detection ◽

Breast Reconstruction ◽

Near Infrared ◽

Diep Flap ◽

Baseline Measurement ◽

Flap Surgery ◽

Level Of Evidence ◽

Non Invasive ◽

Vascular Compromise ◽

Tissue Oximetry

Abstract Early detection of vascular compromise after autologous breast reconstruction is crucial to enable timely re-exploration for flap salvage. Several studies proposed non-invasive tissue oximetry for early identification of ischemia of deep inferior epigastric perforator (DIEP) flaps. The present study aimed to explore the utility of non-invasive tissue oximetry following DIEP flap surgery using a personalized oxygenation threshold. Methods Patients undergoing immediate/delayed DIEP flap surgery were included in this prospective observational study. DIEP flap tissue oxygenation (StO2) was monitored continuously using near-infrared spectroscopy. A baseline measurement was performed by positioning one sensor at the marked position of the major inferior epigastric perforator on the abdomen. A new sensor was positioned postoperatively on the transplanted tissue. In unilateral procedures, postoperative StO2 values of the native breast were also obtained. Measurements were continued for 24 h. Results Thirty patients (42 flaps) were included. Fourteen patients (46.7%) had an uncomplicated postoperative course. A minor complication was observed in thirteen patients; in five patients, at least one major complication occurred, requiring re-exploration. Median StO2 readings were significantly lower in patients with major complications compared to uncomplicated cases. In fourteen unilateral DIEP flap procedures, StO2 values of the native breast were similar to the preoperative baseline measurement (92%; p = 0.452). Conclusions Non-invasive tissue oximetry following DIEP flap surgery could aid in early detection of vascular compromise. StO2 values of the native breast and abdominal wall preoperatively can be used interchangeably and can serve as personalized reference value. Level of evidence: Level IV, diagnostic / prognostic study.

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Breast softness in patients randomised to postmastectomy breast reconstruction with an expander prosthesis or DIEP flap

European Journal of Plastic Surgery ◽

10.1007/s00238-021-01835-z ◽

2021 ◽

Author(s):

Linda Tallroth ◽

Håkan Brorson ◽

Nathalie Mobargha ◽

Patrik Velander ◽

Stina Klasson ◽

...

Keyword(s):

Breast Reconstruction ◽

Subjective Evaluation ◽

Objective Evaluation ◽

Applanation Tonometry ◽

Diep Flap ◽

Level Of Evidence ◽

Patient Reported ◽

Delayed Breast Reconstruction ◽

Level I ◽

Therapeutic Study

Abstract Background Objectively measured breast softness in reconstructed breasts and its relation to patients’ subjective satisfaction with breast softness has not yet been investigated. The aim of this study was to evaluate breast softness in patients 1 year following delayed breast reconstruction with an expander prosthesis (EP) or deep inferior epigastric perforator (DIEP) flap, using objective and subjective methods. Methods Seventy-three patients were randomised to breast reconstruction with an EP or DIEP flap between 2012 and 2018. Of these, 69 completed objective evaluation at a mean of 25 (standard deviation, SD 9.4) months following breast reconstruction. Objective evaluation included measurements of breast volume, jugulum-nipple distance, clavicular-submammary fold distance, ptosis and Baker scale grading. Breast softness was assessed with applanation tonometry. Subjective evaluation was performed using the BREAST-Q questionnaire. Results Objectively, DIEP flaps were significantly softer than EP breast reconstructions. Non-operated contralateral breasts were significantly softer compared with reconstructed breasts. In the subjective evaluation, the median score on the question (labelled 1.h) “How satisfied or dissatisfied have you been with the softness of your reconstructed breast (s)?” was higher in the DIEP flap group corresponding to greater satisfaction in this group. A fair correlation was found between the applanation tonometry and the patient-reported satisfaction with the reconstructed breast’s softness (rs = 0.37). Conclusions In terms of breast softness, breast reconstructions with DIEP flaps result in more satisfied patients. Concerning applanation tonometry as an objective tool for softness assessment, future studies on interobserver agreement are warranted. Level of evidence: Level I, therapeutic study

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Stratification of Surgical Risk in DIEP Breast Reconstruction Based on Classification of Obesity

Journal of Reconstructive Microsurgery ◽

10.1055/s-0041-1727202 ◽

2021 ◽

Author(s):

Charles W. Patterson ◽

Patrick A. Palines ◽

Matthew J. Bartow ◽

Daniel J. Womac ◽

Jamie C. Zampell ◽

...

Keyword(s):

Breast Reconstruction ◽

Full Range ◽

Donor Site ◽

World Health ◽

Morbidly Obese ◽

Diep Flap ◽

Obese Patients ◽

Class Iii ◽

Recipient Site ◽

Surgical Risk

Abstract Background From both a medical and surgical perspective, obese breast cancer patients are considered to possess higher risk when undergoing autologous breast reconstruction relative to nonobese patients. However, few studies have evaluated the continuum of risk across the full range of obesity. This study sought to compare surgical risk between the three World Health Organization (WHO) classes of obesity in patients undergoing deep inferior epigastric perforator (DIEP) flap breast reconstruction. Methods A retrospective review of 219 obese patients receiving 306 individual DIEP flaps was performed. Subjects were stratified into WHO obesity classes I (body mass index [BMI]: 30–34), II (BMI: 35–39), and III (BMI: ≥ 40) and assessed for risk factors and postoperative donor and recipient site complications. Results When examined together, the rate of any complication between the three groups only trended toward significance (p = 0.07), and there were no significant differences among rates of specific individual complications. However, logistic regression analysis showed that class III obesity was an independent risk factor for both flap (odds ratio [OR]: 1.71, 95% confidence interval [CI]: 0.91–3.20, p = 0.03) and donor site (OR: 2.34, 95% CI: 1.09–5.05, p = 0.03) complications. Conclusion DIEP breast reconstruction in the obese patient is more complex for both the patient and the surgeon. Although not a contraindication to undergoing surgery, obese patients should be diligently counseled regarding potential complications and undergo preoperative optimization of health parameters. Morbidly obese (class III) patients should be approached with additional caution, and perhaps even delay major reconstruction until specific BMI goals are met.

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The Impact of Combined Risk-Reducing Gynecological Surgeries on Outcomes in DIEP Flap and Tissue-Expander Breast Reconstruction

Plastic Surgery ◽

10.1177/2292550320925905 ◽

2020 ◽

Vol 28 (2) ◽

pp. 112-116

Author(s):

Avinash P. Jayaraman ◽

Travis Boyd ◽

Savannah N. Hampton ◽

Nicholas T. Haddock ◽

Sumeet S. Teotia

Keyword(s):

Breast Reconstruction ◽

Tissue Expander ◽

Diep Flap ◽

Group 4 ◽

Flap Loss ◽

Hospital Stays ◽

Group 3 ◽

Group 2 ◽

Risk Reducing ◽

Group 1

Introduction: In addition to prophylactic mastectomies, BRCA1 and BRCA2 mutation carriers are increasingly choosing to undergo risk-reducing procedures such as hysterectomies and salpingo-oophorectomies. Sometimes these surgeries are performed in the same visit as a mastectomy or a revisionary reconstruction procedure. Literature lacks descriptions of complications and trends for these combined surgeries. Methods: Group 1 patients (n = 10, flaps = 20) had abdominal gynecologic procedures at the time of deep inferior epigastric artery perforator flap (DIEP flap) reconstruction. Group 2 patients (n = 29, breasts = 58) had gynecologic procedures at the time of mastectomy and tissue-expander placement. Group 3 patients (n = 141, breasts = 257) had mastectomy and tissue-expander reconstruction without gynecologic procedures and were used as a control group for group 2. Group 4 patients (n = 357, flaps = 673) had autologous breast reconstruction without gynecologic procedures and were used as a control for group 1. Categorical variables such as complications and flap loss were analyzed using χ2 tests. Continuous variables such as age, body mass index (BMI), operative time, length of stay were analyzed with 2-tailed t tests. Multivariate analyses were run to control for group differences. Results: Groups 1 and 4 were equivalent in age and comorbidities, except group 1 (32.8 kg/m2) had significantly higher BMI than group 4 (31.4 kg/m2), P = .028. Average operating time was statistically equivalent for group 1 patients (610 minutes) and group 4 patients (503 minutes), P = .289. Average hospital stay was equivalent as well (group 1 = 4.4 days, group 4 = 4.1 days, P = .676). Operative times for group 2 patients (457 minutes) were significantly longer than for group 3 patients (288 minutes), P < .01. Group 2 patients (3 nights) had significantly longer hospital stays than group 3 patients (2 nights), P < .01. Group 1 patients (2/20 flaps, 10%) had a significantly higher rate of flap loss than group 4 patients (8/673 flaps, 1%), P < .01. There were no differences in other flap complications. Additionally, there were no significant differences in postoperative tissue-expander complications between group 2 and group 3. Discussion: Both flap losses in Group 1 patients occurred in a single patient with BMI = 39.3 kg/m2 and a personal history of recurrent DVTs. Additionally, the rates of complications across other measures were equivalent between groups. Thus, despite the increased rate of flap loss in Group 1 (10%) vs Group 4 (1.3%), along with the increased operative times and hospital stays, certain patients can be advised that a prophylactic gynecological procedure is safe to combine with breast reconstruction.

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Safety of Coupled Arterial Anastomosis in Autologous Breast Reconstruction

Journal of Reconstructive Microsurgery ◽

10.1055/s-0040-1715585 ◽

2020 ◽

Author(s):

Mariel McLaughlin ◽

Brooke E. Porter ◽

Rachel Cohen-Shohet ◽

Mark M. Leyngold

Keyword(s):

Breast Reconstruction ◽

Operating Room ◽

Retrospective Chart Review ◽

Free Flaps ◽

Recipient Site ◽

Flap Loss ◽

Increased Risk ◽

Significant Difference ◽

Internal Mammary ◽

Arterial Anastomosis

Abstract Background This study compares the outcomes of coupled versus hand-sewn arterial anastomosis in microvascular breast reconstruction. Methods Retrospective chart review of breast reconstruction free flaps performed between 2013 and 2018 was conducted. Primary end points included flap loss, intraoperative arterial anastomosis revision, and operating room takeback. The decision to couple the arterial anastomosis was based on patient's age, surgeon's preference, history of radiation, and vessel quality. All anastomoses were performed under ×3.5 loupe magnification to internal mammary or thoracodorsal vessels. Results Authors reviewed 104 free flaps; two were lost in hand-sewn group; no flaps were lost in coupled group. There was no significant difference in anastomotic revision rate between coupled and hand-sewn arterial anastomosis (p = 0.186) or return to operating room (OR) between coupled and hand-sewn flaps (p = 1.000). Reasons for takeback included venous congestion and hematoma. Conclusion This study reflects that coupled arterial anastomosis in breast reconstruction may be safely performed without increased risk in anastomotic revision, takeback, or flap loss. Decision to couple should be based on surgeon skill, patient age and history, and assessment of flap and recipient site vasculature.

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The use of the serratus anterior muscle vascular pedicle as recipient site in DIEP flap transfer for breast reconstruction

Journal of Plastic Reconstructive & Aesthetic Surgery ◽

10.1016/j.bjps.2013.12.033 ◽

2014 ◽

Vol 67 (4) ◽

pp. 456-460 ◽

Cited By ~ 6

Author(s):

Fabio Santanelli di Pompeo ◽

Benedetto Longo ◽

Rosaria Laporta ◽

Marco Pagnoni ◽

Enrico Cavalieri

Keyword(s):

Breast Reconstruction ◽

Diep Flap ◽

Vascular Pedicle ◽

Serratus Anterior Muscle ◽

Serratus Anterior ◽

Recipient Site ◽

Flap Transfer

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Institutional Outcomes of Leech Therapy for Venous Congestion in 87 Patients

Journal of Reconstructive Microsurgery ◽

10.1055/s-0037-1604082 ◽

2017 ◽

Vol 33 (09) ◽

pp. 612-618 ◽

Cited By ~ 5

Author(s):

Agustin Cornejo ◽

Ronnie Shammas ◽

Luke Poveromo ◽

Hui-Jie Lee ◽

Scott Hollenbeck

Keyword(s):

Risk Factors ◽

Blood Transfusion ◽

Medical Center ◽

Venous Congestion ◽

Study Cohort ◽

Recipient Site ◽

Reconstructive Procedures ◽

Flap Loss ◽

Leech Therapy ◽

Postoperative Blood Transfusion

Background We aimed to report the outcomes associated with leech therapy and to identify risk factors associated with reconstructive failure. Methods We retrospectively reviewed cases of flap reconstruction or replanted appendages that required leech therapy over an 8-year period at the Duke University Medical Center. Using logistic regression, we assessed the association of risk factors with reconstructive failure. Results The study cohort included 87 patients which correspond to 2.1% of 4,115 cases done during the study period. The most common flap recipient site was the lower extremity (n = 33, 37.9%) followed by the upper extremity (n = 30, 34.5%), head and neck (n = 13, 14.9%), and trunk (n = 11, 12.6%). Flap types were pedicled in 44 (50.5%) cases and free in 24 (27.5%) cases. Fifteen (17.2%) were digital replantation, and four (4.5%) were replanted appendages. The average duration of therapy was 4.6 days (range: 1–11). The overall leech therapy success rate was 60.9% (53/87) and accounted for cases without flap loss (n = 45, 51.7%) and with partial flap loss in which the original reconstructive goal was achieved without further reconstructive procedures (n = 8, 9.2%). Postoperative blood transfusion was administered in 32 (36.7%) cases, and infectious complications occurred in 7 cases in spite of the administration of prophylactic antibiotics (8%). Conclusions This study represents the largest single-institution series evaluating the outcomes after leech therapy. Our data support the use of leeches as an adjunct for the management of venous congestion after reconstructive surgery. However, the morbidity associated with it should be considered, particularly the need for a blood transfusion.

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Chance to cut: defining a negative exploration rate in patients with suspected necrotizing soft tissue infection

Trauma Surgery & Acute Care Open ◽

10.1136/tsaco-2018-000264 ◽

2019 ◽

Vol 4 (1) ◽

pp. e000264 ◽

Cited By ~ 3

Author(s):

Erin C Howell ◽

Jessica A Keeley ◽

Amy H Kaji ◽

Molly R Deane ◽

Dennis Y Kim ◽

...

Keyword(s):

Soft Tissue ◽

Medical Center ◽

Disease Process ◽

P Value ◽

Small Subset ◽

Initial Operation ◽

Level Of Evidence ◽

Exact Test ◽

Surgical Exploration ◽

Cell Counts

BackgroundNecrotizing soft tissue infections (NSTI) are aggressive infections associated with significant morbidity and mortality. Despite multiple predictive models for the identification of NSTI, a subset of patients will not have an NSTI at the time of surgical exploration. We hypothesized there is a subset of patients without NSTI who are clinically indistinguishable from those with NSTI. We aimed to characterize the differences between NSTI and non-NSTI patients and describe a negative exploration rate for this disease process.MethodsWe conducted a retrospective review of adult patients undergoing surgical exploration for suspected NSTI at our county-funded, academic-affiliated medical center between 2008 and 2015. Patients were identified as having NSTI or not (non-NSTI) based on surgical findings at the initial operation. Pathology reports were reviewed to confirm diagnosis. The NSTI and non-NSTI patients were compared using χ2test, Fisher’s exact test, and Wilcoxon rank-sum test as appropriate. A p value <0.05 was considered significant.ResultsOf 295 patients undergoing operation for suspected NSTI, 232 (79%) were diagnosed with NSTI at the initial operation and 63 (21%) were not. Of these 63 patients, 5 (7.9%) had an abscess and 58 (92%) had cellulitis resulting in a total of 237 patients (80%) with a surgical disease process. Patients with NSTI had higher white cell counts (18.5 vs. 14.9 k/mm3, p=0.02) and glucose levels (244 vs. 114 mg/dL, p<0.0001), but lower sodium values (130 vs. 134 mmol/L, p≤0.0001) and less violaceous skin changes (9.2% vs. 23.8%, p=0.004). Eight patients (14%) initially diagnosed with cellulitis had an NSTI diagnosed on return to the operating room for failure to improve.ConclusionsClinical differences between NSTI and non-NSTI patients are subtle. We found a 20% negative exploration rate for suspected NSTI. Close postoperative attention to this cohort is warranted as a small subset may progress.Level of evidenceRetrospective cohort study, level III.

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Major Short-term Complications of Arterial Cannulation for Monitoring in Children

Anesthesiology ◽

10.1097/aln.0000000000003594 ◽

2020 ◽

Vol 134 (1) ◽

pp. 26-34

Author(s):

Stephen J. Gleich ◽

Ashley V. Wong ◽

Kathryn S. Handlogten ◽

Daniel E. Thum ◽

Michael E. Nemergut

Keyword(s):

Medical Center ◽

Academic Medical Center ◽

Major Complication ◽

Anatomical Site ◽

Complication Rates ◽

Arterial Cannulation ◽

Short Term ◽

Anesthetic Care ◽

Major Complications ◽

Cardiac Procedures

Background Perioperative arterial cannulation in children is routinely performed. Based on clinical observation of several complications related to femoral arterial lines, the authors performed a larger study to further examine complications. The authors aimed to (1) describe the use patterns and incidence of major short-term complications associated with arterial cannulation for perioperative monitoring in children, and (2) describe the rates of major complications by anatomical site and age category of the patient. Methods The authors examined a retrospective cohort of pediatric patients (age less than 18 yr) undergoing surgical procedures at a single academic medical center from January 1, 2006 to August 15, 2016. Institutional databases containing anesthetic care, arterial cannulation, and postoperative complications information were queried to identify vascular, neurologic, and infectious short term complications within 30 days of arterial cannulation. Results There were 5,142 arterial cannulations performed in 4,178 patients. The most common sites for arterial cannulation were the radial (N = 3,395 [66.0%]) and femoral arteries (N = 1,528 [29.7%]). There were 11 major complications: 8 vascular and 3 infections (overall incidence, 0.2%; rate, 2 per 1,000 lines; 95% CI, 1 to 4) and all of these complications were associated with femoral arterial lines in children younger than 5 yr old (0.7%; rate, 7 per 1,000 lines; 95% CI, 4 to 13). The majority of femoral lines were placed for cardiac procedures (91%). Infants and neonates had the greatest complication rates (16 and 11 per 1,000 lines, respectively; 95% CI, 7 to 34 and 3 to 39, respectively). Conclusions The overall major complication rate of arterial cannulation for monitoring purposes in children is low (0.2%). All complications occurred in femoral arterial lines in children younger than 5 yr of age, with the greatest complication rates in infants and neonates. There were no complications in distal arterial cannulation sites, including more than 3,000 radial cannulations. Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New

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Teaching Microsurgical Breast Reconstruction—A Retrospective Cohort Study

Journal of Clinical Medicine ◽

10.3390/jcm10245875 ◽

2021 ◽

Vol 10 (24) ◽

pp. 5875

Author(s):

Sebastian Fischer ◽

Yannick F. Diehm ◽

Dimitra Kotsougiani-Fischer ◽

Emre Gazyakan ◽

Christian A. Radu ◽

...

Keyword(s):

Breast Reconstruction ◽

Perforator Flap ◽

Free Flaps ◽

Training Group ◽

Diep Flap ◽

Complication Rates ◽

Recipient Site ◽

Senior Surgeon ◽

Active Training ◽

Passive Training

Microsurgical breast reconstruction demands the highest level of expertise in both reconstructive and aesthetic plastic surgery. Implementation of such a complex surgical procedure is generally associated with a learning curve defined by higher complication rates at the beginning. The aim of this study was to present an approach for teaching deep inferior epigastric artery perforator (DIEP) and transverse upper gracilis (TUG) flap breast reconstruction, which can diminish complications and provide satisfying outcomes from the beginning. DIEP and TUG flap procedures for breast reconstruction were either performed by a senior surgeon (>200 DIEP/TUG, ”no-training group”), or taught to one of five trainees (>80 breast surgeries; >50 free flaps) in a step-wise approach. The latter were either performed by the senior surgeon, and a trainee was assisting the surgery (“passive training”); by the trainee, and a senior surgeon was supervising (“active training”); or by the trainee without a senior surgeon (“after training”). Surgeries of each group were analyzed regarding OR-time, complications, and refinement procedures. A total of 95 DIEP and 93 TUG flaps were included into this study. Before the first DIEP/TUG flap without supervision, each trainee underwent a mean of 6.8 DIEP and 7.3 TUG training surgeries (p > 0.05). Outcome measures did not reveal any statistically significant differences (passive training/active training/after training/no-training: OR-time (min): DIEP: 331/351/338/304 (p > 0.05); TUG: 229/214/239/217 (p > 0.05); complications (n): DIEP: 6/13/16/11 (p > 0.05); TUG: 6/19/23/11 (p > 0.05); refinement procedures (n): DIEP:71/63/49/44 (p > 0.05); TUG: 65/41/36/56 (p > 0.05)), indicating safe and secure implementation of this step-wise training approach for microsurgical breast reconstruction in both aesthetic and reconstructive measures. Of note, despite being a perforator flap, DIEP flap required no more training than TUG flap, highlighting the importance of flap inset at the recipient site.

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