Changes to Venous Flow Coupler Signal during DIEP Flap Inset Can Be Predictive of Poor Clinical Outcomes in Autologous Breast Reconstruction

2020 ◽  
Vol 36 (06) ◽  
pp. 466-470 ◽  
Author(s):  
Salih Colakoglu ◽  
Ariel Johnson ◽  
Jaclyn Anderson ◽  
David Woodbridge Mathes ◽  
Tae Woon Chong
Keyword(s):  
Breast Reconstruction ◽  
Clinical Outcomes ◽  
Free Flap ◽  
Free Flaps ◽  
Patient Characteristics ◽  
Diep Flap ◽  
Signal Loss ◽  
Venous Anastomosis ◽  
Venous Flow ◽  
Venous Signal

Abstract Background Venous flow couplers are typically used to monitor free flaps during the postoperative period, with a continuous venous signal available immediately after completion of the anastomosis. Intraoperative loss of the coupler signal is not uncommon and may require adjustments in free flap inset and even flap thickness to get the venous signal to return. The effects of intraoperative coupler signal loss and the role of this technology on flap outcomes have not been evaluated. We hypothesized that the use of intraoperative coupler can be protective of both early and late flap complications by preventing unfavorable flap insets. Patients and Methods All patients who underwent free flap breast reconstruction between January 2018 and June 2019 by single microsurgery team were included. Flap inset and inset changes based on flow coupler signal problems were reviewed in the procedure notes. Patient demographics data and clinical outcomes were analyzed with comprehensive chart review. Results Forty-four consecutive patients with 69 free flaps were identified. There were no significant differences in patient characteristics or venous coupler size used in venous anastomosis. Although the number of operating room take backs for venous insufficiency was not significantly different between two groups, the free flaps with inset change had significantly higher complications that required later surgical intervention (p = 0.0464). Conclusion Surgeons should be aware that intraoperative coupler signal loss can be associated with poor clinical outcomes postoperatively and these flaps may require more perfusion imaging, flap debulking, or even additional venous anastomosis.

The “Dual-Plane” DIEP Flap: Measuring the Effects of Superficial Arterial and Venous Flow Augmentation on Clinical Outcomes

2019 ◽  
Vol 35 (06) ◽  
pp. e1-e1
Author(s):  
Alex J. Davies ◽  
Ahmed T. Emam ◽  
Giulia Colavitti ◽  
Sherif Wilson
Keyword(s):  
Clinical Outcomes ◽  
Diep Flap ◽  
Venous Flow ◽  
Dual Plane

scholarly journals Use of the Retrograde Recipient Vein for Additional Outflow in Free Tissue Transfer

2020 ◽  
Vol 05 (01) ◽  
pp. e1-e6
Author(s):  
Tetsuji Uemura ◽  
Mamoru Kikuchi ◽  
Hidetaka Watanabe ◽  
Tetsu Yanai
Keyword(s):  
Head And Neck ◽  
Free Tissue Transfer ◽  
Blood Perfusion ◽  
Free Flaps ◽  
Successful Outcome ◽  
Venous Anastomosis ◽  
Venous Flow ◽  
Flap Transfer ◽  
Tissue Transfer ◽  
Free Flap Transfer

Abstract Background The selection of appropriate recipient vessels is essential to the successful outcome of free flap transfer. To improve blood perfusion after reconstruction and reduce the risk of postoperative obstruction of flap vessels, multiple vessels should be chosen as candidate recipients. Methods For certainty of venous drainage, we have been performing venous anastomosis to the distal end of the recipient vein to utilize the reverse venous flow. Results A total of 48 cases of reconstruction of the head and neck or breast region with free flaps using retrograde venous anastomosis were performed. The method possibly improves flap circulation and the success rate of the free tissue transfer and reduces the need to extend surgery to search for multiple recipient veins. Conclusion We emphasized that retrograde limb of vein is useful as a second and/or rescued recipient in free tissue transfer. Retrograde venous anastomosis is a fine and reasonable option when appropriate recipient vessels cannot be found near the defect in the head and neck such as frozen neck or breast region.

scholarly journals Teaching Microsurgical Breast Reconstruction—A Retrospective Cohort Study

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.

Complications and Cost Analysis of Intraoperative Arterial Complications in Head and Neck Free Flap Reconstruction

2017 ◽  
Vol 33 (05) ◽  
pp. 318-327 ◽  
Author(s):  
Michael Chu ◽  
Jonas Nelson ◽  
Marten Basta ◽  
Patrick Gerety ◽  
Suhail Kanchwala ◽  
...  
Keyword(s):  
Regression Analysis ◽  
Head And Neck ◽  
Free Flap ◽  
Free Flaps ◽  
Head And Neck Reconstruction ◽  
Venous Anastomosis ◽  
Factors Associated ◽  
Neck Reconstruction ◽  
Arterial Complications ◽  
The Impact

Background Microvascular anastomotic patency is fundamental to head and neck free flap reconstructive success. The aims of this study were to identify factors associated with intraoperative arterial anastomotic issues and analyze the impact on subsequent complications and cost in head and neck reconstruction. Methods A retrospective review was performed on all head and neck free flap reconstructions from 2005 to 2013. Patients with intraoperative, arterial anastomotic difficulties were compared with patients without. Postoperative outcomes and costs were analyzed to determine factors associated with microvascular arterial complications. A regression analysis was performed to control for confounders. Results Total 438 head and neck free flaps were performed, with 24 (5.5%) having intraoperative arterial complications. Patient groups and flap survival between the two groups were similar. Free flaps with arterial issues had higher rates of unplanned reoperations (p < 0.001), emergent take-backs (p = 0.034), and major surgical (p = 0.002) and respiratory (p = 0.036) complications. The overall cost of reconstruction was nearly double in patients with arterial issues (p = 0.001). Regression analysis revealed that African American race (OR = 5.5, p < 0.009), use of vasopressors (OR = 6.0, p = 0.024), end-to-side venous anastomosis (OR = 4.0, p = 0.009), and use of internal fixation hardware (OR =3.5, p = 0.013) were significantly associated with arterial complications. Conclusion Intraoperative arterial complications may impact complications and overall cost of free flap head and neck reconstruction. Although some factors are nonmodifiable or unavoidable, microsurgeons should nonetheless be aware of the risk association. We recommend optimizing preoperative comorbidities and avoiding use of vasopressors in head and neck free flap cases to the extent possible.

scholarly journals Lessons Learned from 30 Years of Transverse Myocutaneous Gracilis Flap Breast Reconstruction: Historical Appraisal and Review of the Present Literature and 300 Cases

2021 ◽  
Vol 10 (16) ◽  
pp. 3629
Author(s):  
Laurenz Weitgasser ◽  
Maximilian Mahrhofer ◽  
Karl Schwaiger ◽  
Kathrin Bachleitner ◽  
Elisabeth Russe ◽  
...  
Keyword(s):  
Breast Reconstruction ◽  
Donor Site ◽  
Free Flaps ◽  
Lessons Learned ◽  
Diep Flap ◽  
Patient Demographics ◽  
Pedicle Length ◽  
History Of ◽  
Deep Inferior Epigastric Perforator ◽  
Low Bmi

Background: Happy 30th birthday to the transverse myocutaneous gracilis (TMG) flap. Since 1991 the TMG flap has been used to reconstruct a wide variety of defects and became a workhorse flap and reliable alternative to the deep inferior epigastric perforator (DIEP) flap in many breast reconstruction services worldwide. This manuscript sheds light on the history and success of the TMG flap by critically reviewing the present literature and a series of 300 patients receiving a breast reconstruction. Patients and Methods: The present literature and history of the TMG flap was reviewed and a retrospective double center cohort study of 300 free TMG free flaps for autologous breast reconstruction was conducted. Patient demographics, perioperative data, and post-operative complications were recorded and compared with literature findings. Results: Mean flap weight was 320 g. Mean pedicle length was 70 mm. Complications included 19 (6.3%) flap loss. 10 patients (3.3%) had postoperative cellulitis and 28 (9.3%) wound healing disturbance of the donor site. Conclusion: Recipient and donor site complications were comparable to other free flaps used for breast reconstruction. A low BMI or the lack of an abdominal based donor site do not represent a limitation for breast reconstruction and can be overcome using the TMG flap.

The “Dual-Plane” DIEP Flap: Measuring the Effects of Superficial Arterial and Venous Flow Augmentation on Clinical Outcomes

2019 ◽  
Vol 35 (06) ◽  
pp. 411-416 ◽  
Author(s):  
Hani Sbitany ◽  
Rachel Lentz ◽  
Merisa Piper
Keyword(s):  
Vascular System ◽  
Free Flaps ◽  
Diep Flap ◽  
Fat Necrosis ◽  
Venous Flow ◽  
Dual Plane ◽  
Time Period ◽  
Delayed Healing ◽  
Deep Inferior Epigastric Perforator ◽  
Flap Perfusion

Background Deep inferior epigastric perforator (DIEP) flaps are routinely elevated on a single dominant perforator from the deep epigastric vascular system. However, the single perforator may not always perfuse an entire flap adequately, particularly suprascarpal tissue. We often perform “dual-plane” single perforator DIEP flaps by rerouting the superficial (SIEA/V) system directly into a branch of the deep (DIEA/V) vascular system pedicle, thus allowing both systems to contribute and enhance flap perfusion. Methods A prospectively collected database of patients undergoing microvascular breast reconstruction was reviewed for patients undergoing “dual-plane” DIEP flaps. These were matched to a similar cohort of patients undergoing “traditional” single perforator DIEP free flaps over the same time period. Treatment demographics and flap-specific morbidity outcomes were assessed, including performance in the setting of radiation. Results Over 2 years, 23 “dual-plane” DIEP flaps were performed (15 patients), compared with 35 single-perforator “traditional” DIEP flaps (23 patients). Rates of delayed healing were similar between both cohorts (2.9 vs. 4.3%, p = 0.28). Rates of palpable fat necrosis were significantly lower in “dual-plane” DIEP flaps compared with “traditional” flaps (0 vs. 14.3%, p = 0.03). Rates of clinically palpable fat necrosis following radiation were significantly lower in the “dual-plane” flaps (4.3 vs. 40%, p = 0.02). Conclusion The “dual-plane” DIEP flap is one we routinely consider in our algorithm, as it allows for full preservation of functional abdominal musculature, and offers enhanced flap perfusion by incorporating both the deep and superficial (dominant) vascular systems. This results in lower fat necrosis rates, particularly in the setting of post-reconstruction radiation.

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