scholarly journals Successful Deep Inferior Epigastric Perforator Flap Harvest despite Preoperative Therapeutic Subcutaneous Heparin Administration into the Abdominal Pannus

2016 ◽  
Vol 2016 ◽  
pp. 1-4
Author(s):  
Joseph W. Duncumb ◽  
Kana Miyagi ◽  
Parto Forouhi ◽  
Charles M. Malata
Keyword(s):  
Perforator Flap ◽  
Rectus Muscle ◽  
Free Flaps ◽  
Diep Flap ◽  
External Compression ◽  
Heparin Administration ◽  
Deep Inferior Epigastric Perforator ◽  
Therapeutic Doses ◽  
Flap Perfusion ◽  
Haematoma Formation

Abdominal free flaps for microsurgical breast reconstruction are most commonly harvested based on the deep inferior epigastric vessels that supply skin and fat via perforators through the rectus muscle and sheath. Intact perforator anatomy and connections are vital for subsequent optimal flap perfusion and avoidance of necrosis, be it partial or total. The intraflap vessels are delicate and easily damaged and it is generally advised that patients should avoid heparin injection into the abdominal pannus preoperatively as this may compromise the vascular perforators through direct needle laceration, pressure from bruising, haematoma formation, or perforator thrombosis secondary to external compression. We report three cases of successful deep inferior epigastric perforator (DIEP) flap harvest despite patients injecting therapeutic doses of low molecular weight heparin into their abdomens for thrombosed central venous lines (portacaths™) used for administering primary chemotherapy in breast cancer.

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.

Alternative flaps for microsurgical breast reconstruction

2021 ◽  
pp. 1107-1114
Author(s):  
Hinne A. Rakhorst
Keyword(s):  
Breast Reconstruction ◽  
Standard Care ◽  
Donor Site ◽  
Perforator Flap ◽  
Donor Site Morbidity ◽  
The Body ◽  
Diep Flap ◽  
Deep Inferior Epigastric Perforator ◽  
Muscle Sparing ◽  
Breast Reconstructive Surgery

Microsurgery in general has made dramatic improvements over the past decades. This applies to microsurgery in general and to breast reconstructive surgery especially. The demand for autologous breast reconstruction has risen. Since the introduction of the free transverse rectus abdominis myocutaneous (TRAM) flaps, through the muscle-sparing TRAM, flaps designs have evolved into the current gold standard, the deep inferior epigastric perforator (DIEP) flap. From experiences and increasing numbers of flap procedures performed by surgeons, techniques became more familiar and part of standard care. These factors gave rise to the development of a growing number of areas of the body where tissues of interest can be harvested using perforator flap-based techniques. This chapter discusses the most common as well as the ‘rising stars’ in terms of flaps to be used as alternative flaps to the DIEP flap for breast reconstruction. It discusses practical issues on dissection as well as donor site morbidity.

Fat-Augmented Latissimus Dorsi versus Deep Inferior Epigastric Perforator Flap: Comparative Study in Delayed Autologous Breast Reconstruction

2020 ◽  
Author(s):  
Efterpi C. Demiri ◽  
Antonios Tsimponis ◽  
Anastasios Pagkalos ◽  
Eleni Georgiadou ◽  
Olga-Christina Goula ◽  
...  
Keyword(s):  
Breast Reconstruction ◽  
Demographic Data ◽  
Perforator Flap ◽  
Diep Flap ◽  
Breast Volume ◽  
Autologous Breast Reconstruction ◽  
Patients Satisfaction ◽  
Delayed Breast Reconstruction ◽  
Group A ◽  
Deep Inferior Epigastric Perforator

Abstract Background The use of autologous tissues is considered the mainstay for delayed breast reconstruction. Aside the free abdominal flaps, which are most commonly used, the fat-augmented latissimus-dorsi (FALD) flap has been recently shown a reliable alternative option for pure autologous breast reconstruction. In this retrospective study, we aim to compare outcomes of autologous breast reconstructions using the extended FALD and deep inferior epigastric perforator flap (DIEP) flap, with an emphasis on patients' characteristics, demographic data, complications, and patients' satisfaction after a minimum 12-month follow-up. Methods Our series consists of 135 women who underwent a delayed postmastectomy unilateral autologous breast reconstruction from 2011 to 2017: 36 patients (Group A) had an extended FALD flap and 99 (Group B) a free DIEP flap performed by the same surgeons. Demographic data, breast volume, medical history, smoking, complications, and patients' satisfaction were recorded and analyzed. Student's t-test for independent variables, Mann–Whitney U-test, and Chi-squared test were used to compare the reported variables. Results Patients' age, body mass index (BMI), and pregnancy history were statistically different between groups (p < 0.001, p = 0.004, p < 0.001, respectively); younger age (35.1 vs. 41.2 years), lower BMI (25.6 vs. 28.4), and fewer pregnancies were recorded in Group A. Breast volume was also found significantly smaller in Group A patients (p = 0.009). Past medical history using the ASA physical status classification score, previous radiation therapy, history of smoking, and incidence of overall complications were similar in both groups. Overall satisfaction scores were found slightly higher, but not statistically significant, in the free-flap group (p = 0.442). Conclusion The use of the FALD flap may provide comparable outcome to the DIEP flap in delayed breast reconstruction in terms of complications and patients' satisfaction; it should be considered a good reconstructive option for young and thin nulliparous patients, with small to medium size opposite breast.

scholarly journals Outcomes in Deep Inferior Epigastric Perforator Flap and Implant-Based Reconstruction

2018 ◽  
Vol 25 (1) ◽  
pp. 107327481774460 ◽  
Author(s):  
Lauren V. Kuykendall ◽  
Angie Zhang ◽  
Bugra Tugertimur ◽  
Sara Bijan ◽  
Corin Agoris ◽  
...  
Keyword(s):  
Older Patients ◽  
Elderly Population ◽  
Response Rate ◽  
Tissue Expander ◽  
Perforator Flap ◽  
Diep Flap ◽  
Younger Patients ◽  
Significant Difference ◽  
Deep Inferior Epigastric Perforator ◽  
Older Populations

Despite the growing elderly population, there is limited research specific to this demographic concerning breast reconstruction (BR). Lack of evidence-based BR recommendations in older populations may contribute to misconceptions and subsequent underutilization of BR, especially autologous BR. Patients who received either deep inferior epigastric perforator (DIEP) flap BR or tissue expander/implant (TE/I) BR by a single surgeon between July 2011 and July 2015 were surveyed postoperatively by using the psychometrically validated BREAST-Q questionnaire to determine patient satisfaction. Patients were categorized into younger and older cohorts based on median age (55 years) and further stratified based on the type of reconstruction. Of the 311 patients surveyed, 95 patients responded (31% response rate). Overall, younger patients (<55 years old, n = 42) compared with older patients (≥55 years old, n = 53) had significantly higher satisfaction with their outcome (mean difference [MD] 12.06; 95% confidence interval [CI]: 0.96-23.15; P = 0.034). In the TE/I group (n = 58), younger patients had significantly higher satisfaction with breasts (MD: 14.17; 95% CI: 2.58-25.75; P = .017) and outcome (MD: 18.25; 95% CI: 3.95-32.5; P = .010) with fewer complications (odds ratio [OR]: 3.29; 95% CI: 1.37-7.86; P = .010). In the DIEP flap group (n = 55), there was no significant difference inr any of the satisfaction outcomes between younger and older patients. Younger patients tend to be more satisfied and demonstrate fewer complications with implant-based BR. In contrast, both younger and older patients undergoing abdominally based autologous BR were equally satisfied with comparable outcomes.

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.

scholarly journals Economic Analysis of Noninvasive Tissue Oximetry for Postoperative Monitoring of Deep Inferior Epigastric Perforator Flap Breast Reconstruction: A Review

2020 ◽  
pp. 155335062094298
Author(s):  
Anouk A. M. A. Lindelauf ◽  
Nousjka P. A. Vranken ◽  
Vivian G. H. Rutjens ◽  
Rutger M. Schols ◽  
John H. Heijmans ◽  
...  
Keyword(s):  
Economic Analysis ◽  
Breast Reconstruction ◽  
Postoperative Care ◽  
Hospital Costs ◽  
Perforator Flap ◽  
Diep Flap ◽  
Postoperative Monitoring ◽  
Reconstruction Methods ◽  
Deep Inferior Epigastric Perforator ◽  
Tissue Oximetry

Background. Postoperative monitoring of deep inferior epigastric perforator (DIEP) flaps for breast reconstruction using noninvasive tissue oximetry enables timely recognition of vascular compromise. This may limit ischemic tissue damage, minimizing postoperative morbidity and healthcare costs. The aim of this review was to provide an economic analysis of tissue oximetry for postoperative monitoring of DIEP flap breast reconstruction. Methods. A systematic literature search was conducted utilizing PubMed and Embase. Articles reporting costs related to tissue oximetry following DIEP flap breast reconstruction, costs directly related to DIEP flap surgical procedure, and costs associated with postoperative complications were included. Risk of bias was assessed using different tools depending on study type. Results. Six articles were included. Four studies provided an overview of total costs associated with DIEP flap breast reconstruction; two studies focused on whether tissue oximetry could facilitate a decrease in hospital costs. Average overall costs for DIEP flap procedure were estimated at $28 000, with additional costs up to $37 530 in case of total flap failure. Tissue oximetry to monitor DIEP flaps could potentially save up to $1667 per procedure. Moreover, it might eliminate the need for specialized postoperative care. Conclusion. Tissue oximetry following DIEP flap breast reconstruction can potentially facilitate a decrease in hospital costs since its readings enable physicians to intervene in an early stage of tissue malperfusion, contributing to minimizing complications. Tissue oximetry may eliminate the need for specialized postoperative care. However, based on the current literature, no firm conclusions can yet be drawn regarding cost-effectiveness of standard implementation.

scholarly journals Aesthetical outcome after breast reconstruction using deep inferior epigastric perforator flap: Personal techniques

2013 ◽  
Vol 46 (03) ◽  
pp. 513-517 ◽  
Author(s):  
Chiara Gelati ◽  
Luca Negosanti ◽  
Erich Fabbri ◽  
Riccardo Cipriani
Keyword(s):  
Breast Reconstruction ◽  
Perforator Flap ◽  
Diep Flap ◽  
Breast Asymmetry ◽  
Inferior Pole ◽  
The World ◽  
Deep Inferior Epigastric Perforator ◽  
Reconstructed Breast

ABSTRACT Background: Now-a-days, deep inferior epigastric perforator (DIEP) flap breast reconstruction is widespread throughout the world. The aesthetical result is very important in breast reconstruction and its improvement is mandatory for plastic surgeons. Materials and Methods: The most frequent problems, we have observed in breast reconstruction with DIEP flap are breast asymmetry in terms of volume and shape, the bulkiness of the inferior lateral quadrant of the new breast, the loss of volume of the upper pole and the lack of projection of the inferior pole. We proposed our personal techniques to improve the aesthetical result in DIEP flap breast reconstruction. Our experience consists of more than 220 DIEP flap breast reconstructions. Results: The methods mentioned for improving the aesthetics of the reconstructed breast reported good results in all cases. Conclusion: The aim of our work is to describe our personal techniques in order to correct the mentioned problems and improve the final aesthetical outcome in DIEP flap breast reconstruction.

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