Postoperative Free Flap Breast Protocol Optimizing Resources and Patient Safety

Abstract Background As deep inferior epigastric artery perforator (DIEP) flaps have gained popularity in breast reconstruction, the postoperative care of these patients, including the appropriate hospital length-of-stay and the need for intensive care unit (ICU) admission, has become a topic of debate. At our institution, we have adopted a pathway that aims for discharge on postoperative day 3, utilizing continuous tissue oximetry without ICU admission. This study aims to evaluate outcomes with this pathway to assess its safety and feasibility in clinical practice. Methods A retrospective review was performed of patients undergoing DIEP flap breast reconstruction between January 2013 and August 2014. Data of interest included patient demographics and medical history as well as complication rates and date of hospital discharge. Results In total, 153 patients were identified undergoing 239 DIEP flaps. The mean age was 50 years (standard deviation [SD] = 10.2) and body mass index (BMI) 29.4 kg/m2 (SD = 5.2). Over the study period, the flap failure rate was 1.3% and reoperation rate 3.9%. Seventy-one percent of patients were discharged on postoperative day 3. Nine patients required hospitalization beyond 5 days. Theoretical cost savings from avoiding ICU admissions were $1,053 per patient. Conclusion A pathway aiming for hospital discharge on postoperative day 3 without ICU admission following DIEP flap breast reconstruction can be feasibly implemented with an acceptable reoperation and flap failure rate.

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Bilateral Breast Reconstruction with Abdominal Free Flaps: A Single Centre, Single Surgeon Retrospective Review of 55 Consecutive Patients

Plastic Surgery International ◽

10.1155/2016/6085624 ◽

2016 ◽

Vol 2016 ◽

pp. 1-9 ◽

Cited By ~ 6

Author(s):

Peter McAllister ◽

Isabel Teo ◽

Kuen Chin ◽

Boikanyo Makubate ◽

David Alexander Munnoch

Keyword(s):

Breast Reconstruction ◽

Failure Rate ◽

Retrospective Review ◽

Free Tissue Transfer ◽

Free Flaps ◽

Senior Author ◽

Complication Rates ◽

Immediate Reconstruction ◽

Flap Failure ◽

Increased Risk

Breast reconstruction using free tissue transfer is an increasingly utilised oncoplastic procedure. The aim was to review all bilateral breast reconstructions using abdominal free flaps by a single surgeon over an 11-year period (2003–2014). A retrospective review was performed on all patients who underwent bilateral breast reconstruction using abdominal free flaps between 2003 and 2014 by the senior author (DAM). Data analysed included patient demographics, indication for reconstruction, surgical details, and complications. Fifty-five female patients (mean 48.6 years [24–71 years]) had bilateral breast reconstruction. The majority (41, 74.5%) underwent immediate reconstruction and DIEP flaps were utilised on 41 (74.5%) occasions. Major surgical complications occurred in 6 (10.9%) patients, all of which were postoperative vascular compromise of the flap. Failure to salvage the reconstruction occurred on 3 (5.5%) occasions resulting in a total flap failure rate of 2.7%. Obesity (>30 kg/m2) and age > 60 years were shown to have a statistically increased risk of developing postoperative complications (P<0.05). Our experience demonstrates that abdominal free flaps for bilateral breast reconstruction fares well, with a flap failure rate of 2.7%. Increased body mass index and patient age (>60 years) were associated with higher complication rates.

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Use of Strict Patient Selection Criteria to Achieve Significant Surgical Outcomes from a Low DIEP Flap Breast Reconstruction

Journal of Reconstructive Microsurgery ◽

10.1055/s-0039-1692168 ◽

2019 ◽

Vol 35 (08) ◽

pp. 622-630

Author(s):

Han Gyu Cha ◽

Min Kyu Kang ◽

Hyun Ho Han ◽

Eun Key Kim ◽

Jin Sup Eom

Keyword(s):

Breast Reconstruction ◽

Ct Angiography ◽

Patient Selection ◽

Surgical Outcomes ◽

Selection Criteria ◽

Diep Flap ◽

Complication Rates ◽

Abdominal Scar ◽

Significant Difference ◽

Patient Selection Criteria

Abstract Background The low deep inferior epigastric perforator (DIEP) flap was first introduced in 2016 as it had aesthetic advantages over the conventional DIEP flap. With our experience of over 100 low DIEP flap procedures to date, we have conspicuously lowered complication rates and established more definitive criteria to select proper candidates. Methods We analyzed 103 patients who underwent breast reconstruction with the low DIEP flap at our hospital between May 2014 and June 2018. Demographics, patient selection criteria, flap specifics, surgical outcomes including postoperative complications, and the location of the abdominal scar and umbilicus were reviewed retrospectively. Results The mean patient age was 46.7 years, and the average body mass index was 23.7 kg/m2. A low DIEP with an average weight of 377 g was utilized within 6 hours 17 minutes in this cohort. There was no significant difference in the rate of venous congestion or fat necrosis compared with the conventional DIEP flap. The average distance from the pubic hairline to the abdominal scar was 0.6 cm and from the anterior superior iliac spine to the abdominal scar was −0.4 cm. The postoperative location of the umbilicus was 7.0 cm above the pubic hairline. Conclusion The low DIEP flap is not only a reliable option for a breast reconstruction but is an aesthetically superior approach with a lower abdominal scar and natural umbilicus. Patients may benefit from this technique if prudently selected by computed tomography (CT) angiography. A perforator that is larger than 1 mm in diameter and well enhanced on CT angiography from the division of the external iliac artery to the abdominal skin particularly in the intramuscular course should be selected.

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Overall Complication Rates of DIEP Flap Breast Reconstructions in Germany—A Multi-Center Analysis Based on the DGPRÄC Prospective National Online Registry for Microsurgical Breast Reconstructions

Journal of Clinical Medicine ◽

10.3390/jcm10051016 ◽

2021 ◽

Vol 10 (5) ◽

pp. 1016

Author(s):

Paul I. Heidekrueger ◽

Nicholas Moellhoff ◽

Raymund E. Horch ◽

Jörn A. Lohmeyer ◽

Mario Marx ◽

...

Keyword(s):

Breast Reconstruction ◽

Revision Surgery ◽

National Level ◽

Length Of Hospital Stay ◽

High Standard ◽

High Volume ◽

National Registry ◽

Wound Complications ◽

Diep Flap ◽

Complication Rates

While autologous breast reconstruction has gained momentum over recent years, there is limited data on the structure and quality of care of microsurgical breast reconstruction in Germany. Using the breast reconstruction database established by the German Society of Plastic, Reconstructive and Aesthetic Surgeons (DGPRÄC), the presented study investigated the overall outcomes of deep inferior epigastric perforator (DIEP) flap reconstructions in Germany. Data of 3926 patients and 4577 DIEP flaps performed by 22 centers were included in this study. Demographics, patient characteristics, perioperative details and postoperative outcomes were accounted for. Centers performing < Ø 40 (low-volume (LV)) vs. ≥ Ø 40 (high-volume (HV)) annual DIEP flaps were analyzed separately. Overall, total and partial flap loss rates were as low as 2.0% and 1.1% respectively, and emergent vascular revision surgery was performed in 4.3% of cases. Revision surgery due to wound complications was conducted in 8.3% of all cases. Mean operative time and length of hospital stay was significantly shorter in the HV group (LV: 385.82 min vs. HV: 287.14 min; LV: 9.04 (18.87) days vs. HV: 8.21 (5.04) days; both p < 0.05). The outcome and complication rates deduced from the national registry underline the high standard of microsurgical breast reconstruction on a national level in Germany.

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Reducing Length of Stay after Microsurgical Breast Reconstruction with a Standardized Postoperative Protocol

Journal of Reconstructive Microsurgery ◽

10.1055/s-0039-1687916 ◽

2019 ◽

Vol 35 (08) ◽

pp. 557-567

Author(s):

Matthew A. DelMauro ◽

Kevin Chen ◽

Alex Keller

Keyword(s):

Length Of Stay ◽

Breast Reconstruction ◽

Operating Room ◽

Postoperative Care ◽

Enhanced Recovery ◽

Average Length ◽

Free Flaps ◽

Senior Author ◽

Hospital Length Of Stay ◽

Flap Failure

Abstract Background Despite widespread acceptance of enhanced recovery after surgery protocols in other surgical specialties, plastic surgery has been slow to adopt fast-track principles. Recently, however, studies have shown that patients undergoing microsurgical breast reconstruction may benefit from a comprehensive postoperative protocol. Methods All microsurgical breast reconstructions with abdominal free flaps performed by the senior author (A.K.) at a single institution from June 2009 to December 2013 were reviewed. Demographic information (e.g., age, body mass index, and comorbidities), operative details (e.g., laterality, type of flap), and postoperative data (e.g., complications, length of stay) were collected from patients' medical records. The authors employed a universal comprehensive protocol that dictated all postoperative care as it relates to diet, ambulation, flap monitoring, anticoagulation, analgesia, venous thromboembolism, antibiotic prophylaxis, and discharge criteria. Results During the study period, 161 patients underwent 289 free flaps. The average length of stay for all patients was 3.26 ± 1.19 days. The incidence of complications requiring return to the operating room was 4.35% (7 patients). The incidence of flap failure was 0.69% (2 of 289 flaps). Only one flap failure occurred after hospital discharge. Statistical analysis demonstrated that the presence of any complication requiring return to the operating room increased hospital course by an average of 1.37 days (p = 0.0027). Conclusion The standardization of postoperative care for patients undergoing microsurgical breast reconstruction results in a short hospital length of stay without increasing the incidence of flap failure or postoperative complications requiring return to the operating room.

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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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Economic Impact of Refinements in ERAS Pathways in DIEP Flap Breast Reconstruction

Journal of Reconstructive Microsurgery ◽

10.1055/s-0041-1740128 ◽

2021 ◽

Author(s):

Pope Rodnoi ◽

Sumeet S. Teotia ◽

Nicholas T. Haddock

Keyword(s):

Breast Reconstruction ◽

Hospital Length Of Stay ◽

P Value ◽

Diep Flap ◽

Total Cost ◽

Contribution Margin ◽

Significant Difference ◽

Post Hoc ◽

The Impact ◽

Operating Suite

Abstract Introduction Enhanced recovery after surgery (ERAS) protocols at our institution have led to an expected decrease in hospital length of stay and opioid consumption for patients treated with deep inferior epigastric perforator (DIEP) flaps for breast reconstruction. We look to examine the economic patterns across these years to see the impact of costs for the patient and institution. Methods This study retrospectively evaluated consecutive patients treated with bilateral DIEP flaps for breast reconstruction between October 2015 and August 2020. We categorized the cases into three categories: pre-ERAS, ERAS, ERAS + bupivacaine. Primary outcomes observed included the contribution margin per operating suite case minute and total cost to the patient. An analysis of variance determined whether there was a difference between the three groups and a Tukey post-hoc analysis made pairwise comparisons. A p-value < 0.05 was significant. Results A total of 268 cases of bilateral DIEPs performed by the two senior authors were analyzed in this study. Seventy-four cases were pre-ERAS, 72 were ERAS, and 122 were ERAS + bupivacaine. There was a statistical difference between the contribution margin per operating minute. A Tukey post hoc test revealed that the average contribution margin per operating suite case minute was significantly higher for the ERAS and ERAS + bupivacaine compared with the pre-ERAS groups.There was a statistically significant difference between the total cost to the patients. A Tukey post hoc test revealed that the average total cost to the patient was statistically significantly lower for the ERAS and ERAS + bupivacaine compared with the pre-ERAS group. Conclusion Implementation of ERAS and continued improvements in ERAS resulted in significantly decreased costs for the patient and increased profitability for the hospital. Investing in improvements to ERAS protocols can improve profitability for the institution while simultaneously improving costs and access to care for patients in need of breast reconstruction.

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The DIEP Flap as Well-established Method of Choice for Autologous Breast Reconstruction with a Low Complication Rate – Retrospective Single-centre 10-Year Experience

Geburtshilfe und Frauenheilkunde ◽

10.1055/a-1116-2102 ◽

2020 ◽

Vol 80 (06) ◽

pp. 628-638 ◽

Cited By ~ 1

Author(s):

Beatrix Munder ◽

Christoph Andree ◽

Christian Witzel ◽

Sonia Fertsch ◽

Peter Stambera ◽

...

Keyword(s):

Risk Factors ◽

Breast Reconstruction ◽

Complication Rate ◽

Prophylactic Mastectomy ◽

Diep Flap ◽

Complication Rates ◽

Flap Surgery ◽

Autologous Breast Reconstruction ◽

Primary Indication ◽

Low Rate

Abstract Background Breast cancer is the most common cancer affecting women in Germany. Despite breast-conserving therapy (BCT) being carried out in almost 70% of cases, a high number of women still require complete mastectomy. Prophylactic mastectomy is also indicated for women with a BRCA 1/2 gene mutation. In addition to implant-based heterologous breast reconstruction, autologous breast reconstruction using a DIEP flap has been found to be beneficial, particularly for patients who had prior radiotherapy. This study aims to show that DIEP flap reconstruction surgery is the method of choice for autologous breast reconstruction with a low rate of complications. Patients and Methods Autologous breast reconstruction using a DIEP flap was performed in 1124 patients between July 2004 and December 2014. Retrospective study criteria included potential risk factors such as age, BMI, smoking, chemotherapy and/or radiotherapy, and comorbidities as well as outcome parameters such as postoperative complications. Outcomes were evaluated with a mean follow-up of 24 months. Results A total of 1124 patients underwent 1274 free DIEP flap breast reconstructions, of which 150 were bilateral reconstructions. The primary indication was previous mastectomy in 785 cases, followed by prior implant-based reconstruction in 265 cases. The total flap loss rate was 0.6%. Postoperative surgical revision for abdominal wall hernia was required in 0.2% of cases. The group with a higher BMI and the group of smokers had significantly higher complication rates. Elderly patients (> 65 years), patients who had undergone chemo-/radiotherapy and patients with diabetes did not have higher complication rates. Conclusion DIEP flap surgery is an excellent option for autologous breast reconstruction, with a low rate of donor site morbidity and low complication rates. DIEP flap surgery carried out in a specialised interdisciplinary breast centre in a standardised clinical setting after prior careful patient selection to take account of risk factors such as high BMI and smoking is a reliable method with a low complication rate and satisfactory long-term reconstruction results.

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The Deep Inferior Epigastric Perforator (DIEP) Flaps in Breast Reconstruction After Mastectomy

Jurnal Plastik Rekonstruksi ◽

10.14228/jpr.v1i3.66 ◽

1970 ◽

Vol 1 (3) ◽

Author(s):

Dyandra Parikesit ◽

Mark Ashton

Keyword(s):

Breast Reconstruction ◽

Current Knowledge ◽

Subcutaneous Fat ◽

Diep Flap ◽

Tram Flap ◽

Complication Rates ◽

Autologous Breast Reconstruction ◽

Patient Satisfaction Score ◽

Aesthetic Appearance ◽

Deep Inferior Epigastric Perforator

Background: The continuing advances in breast reconstruction surgery allows for high expectation of excellent outcomes and long-term aesthetic appearance. Transverse rectus abdominis muscle (TRAM) flap has been the flap of choice in breast reconstructions for decades, however it sacrifices muscle and causes donor site complication. Deep inferior epigastric perforator (DIEP) flap is now the preferred flap for microsurgical breast reconstruction, because it holds some advantages over TRAM. This study aim to review, summarize, and discuss the current knowledge of DIEP flap in breast reconstruction.Method: Literature research conducted through Pubmed, Medline, and SCOPUS databases for published articles up to the year 2009. A total of 808 articles were found, and 60 articles reviewed.Result: Women with thick subcutaneous fat and skin on the lower abdomen are the most appropriate candidates for autologous breast reconstruction. Patients might be given oral analgesics instead of intravenous, because DIEP results in less postoperative pain than TRAM. Patients are commonly discharged on the 6–7th day post operation after DIEP flaps. In spite of several reports that DIEP flap has low complication rates, necrosis is the most common and often leads to poor cosmetic outcome.Conclusion: DIEP flap essentially combines all the advantages of TRAM flap without most of its disadvantages. Some complications may occur in smaller percentage. Although DIEP flap has a high patient satisfaction score, it does not mean that it is definitely superior to other methods of autologous breast reconstruction.

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