Refractory Donor-Site Seroma Following DIEP Breast Reconstruction

Donor-site seroma formation is a complication of autologous breast reconstruction reported most commonly with the use of latissimus dorsi flaps. First-line treatment is percutaneous aspiration which leads to resolution in the majority of cases. Those that persist may progress to a chronic, refractory seroma, which can prove challenging in terms of treatment. The aim of this article is to provide an updated literature review of interventions for chronic donor-site seroma and present the case of a 65-year-old female with a recalcitrant abdominal seroma following deep inferior epigastric perforator (DIEP) flap breast reconstruction. Literature review revealed a single article that reported 2 cases of persistent donor-site seroma after DIEP flap breast reconstruction. The patient presented here underwent repeat aspiration, drain placement, and multiple surgical procedures to achieve resolution. In total, the post-reconstruction seroma history of the patient extended over approximately 14 months. We conclude with evidence-based suggestions for chronic, donor-site seroma prevention and treatment.

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Unilateral Autologous Breast Reconstruction with Bi-pedicled, Conjoined Deep Inferior Epigastric Perforator Flaps

Journal of Reconstructive Microsurgery ◽

10.1055/s-0038-1668161 ◽

2018 ◽

Vol 35 (02) ◽

pp. 145-155 ◽

Cited By ~ 3

Author(s):

Akhil Seth ◽

Pieter Koolen ◽

Steven Sultan ◽

Bernard Lee ◽

Heather Erhard ◽

...

Keyword(s):

Soft Tissue ◽

Breast Reconstruction ◽

Donor Site ◽

Side Branch ◽

Diep Flap ◽

Autologous Breast Reconstruction ◽

Pedicled Flaps ◽

Skin Envelope ◽

The Status ◽

Deep Inferior Epigastric Perforator

Background The abdomen remains the most popular and reliable donor site for autologous breast reconstruction. Some patients, however, lack sufficient tissue to recreate an aesthetic breast mound using a single-pedicle, deep inferior epigastric perforator (DIEP) flap, particularly when matching a contralateral native breast. The amount of abdominal skin and/or soft tissue reliably supplied by one vascular pedicle is frequently insufficient to adequately restore the breast skin envelope and “footprint.” This study summarizes our experience with using bipedicled DIEP flaps to improve the aesthetic results of unilateral breast reconstruction in such patients. Methods Consecutive patients undergoing unilateral breast reconstruction with bi-pedicled, conjoined DIEP flaps over a 4-year period were retrospectively reviewed. Primary and secondary flap microvascular anastomoses were performed to the antegrade internal mammary (IM) vessels and to either the retrograde IM vessels or a primary DIEP pedicle side branch, respectively. Clinical characteristics and outcomes were recorded. Results Sixty-three patients underwent immediate (n = 29) or delayed (n = 34) reconstruction, with age and body mass index of 54.1 ± 8.4 years and 26.6 ± 4.7, respectively. Mean follow-up was 14.1 months. Twenty-eight (44.4%) patients received prereconstruction radiation therapy. All patients had preoperative abdominal imaging, including 57 (90.5%) using magnetic resonance angiography. There were no flap losses with three operative interventions for flap salvage. Conclusion Unilateral breast reconstruction with bipedicled, conjoined DIEP flaps is safe and reliable. These procedures can be performed with a complication profile similar to single-pedicle DIEP flaps. The additional skin and soft tissue available with bi-pedicled flaps allows for greater flexibility in matching the shape and projection of a woman's contralateral breast, and in some cases is necessary to achieve an aesthetically acceptable reconstruction. With growing expectations among breast reconstruction patients, conjoined bi-pedicled flaps represent a tool for meeting their reconstructive needs and exceeding the status quo for aesthetic outcomes.

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

Journal of Clinical Medicine ◽

10.3390/jcm10163629 ◽

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.

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Alternative flaps for microsurgical breast reconstruction

10.1093/med/9780199682874.003.0093 ◽

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.

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How Does Autologous Breast Reconstruction Impact Downtime?

Journal of Reconstructive Microsurgery ◽

10.1055/s-0038-1641711 ◽

2018 ◽

Vol 34 (07) ◽

pp. 530-536 ◽

Cited By ~ 3

Author(s):

Daniel Rais ◽

Jian Farhadi ◽

Giovanni Zoccali

Keyword(s):

Breast Reconstruction ◽

Donor Site ◽

Diep Flap ◽

Autologous Reconstruction ◽

Autologous Breast Reconstruction ◽

Superior Gluteal Artery ◽

Free Flap Surgery ◽

Recovery Times ◽

Time Required ◽

The Impact

Background Although autologous breast reconstruction is technically quite demanding, it offers the best outcomes in terms of durable results, patient perceptions, and postoperative pain. Many studies have focused on clinical outcomes and technical aspects of such procedures, but few have addressed the impact of various flaps on patient recovery times. This particular investigation entailed an assessment of commonly used flaps, examining the periods of time required to resume daily activities. Methods Multiple choice questionnaires were administered to 121 patients after recovery from autologous reconstruction to determine the times required in returning to specific physical activities. To analyze results, the analysis of variance F-test was applied, and odds ratios (ORs) were determined. Results Among the activities surveyed, recovery time was not always a function of free-flap surgery. Additional treatments and psychological effects also contributed. Adjuvant chemotherapy increased average downtime by 2 weeks, and postoperative irradiation prolonged recovery as much as 4 weeks. Patient downtime was unrelated to flap type, ranging from 2.9 to 21.3 weeks for various activities in question. Deep inferior epigastric perforator (DIEP) flaps yielded the highest OR and transverse upper gracilis (TUG) flaps the lowest. Conclusion Compared with superior gluteal artery perforator and TUG flaps, the DIEP flap was confirmed as the gold standard in autologous breast reconstruction, conferring the shortest recovery times. All adjuvant therapies served to prolong patient recovery as well. Surgical issues, patient lifestyles, and donor-site availability are other important aspects of flap selection.

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

Journal of Reconstructive Microsurgery ◽

10.1055/s-0040-1716348 ◽

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.

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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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A Brief History of Breast Reconstruction and a Discussion of Two Common Autologous Breast Reconstruction Surgeries: The Free Deep Inferior Epigastric Perforator Flap and the Free Transverse Rectus Abdominis Musculocutaneous Flap

Dalhousie Medical Journal ◽

10.15273/dmj.vol38no1.3849 ◽

2011 ◽

Vol 38 (1) ◽

Author(s):

Timothy J Phillips ◽

Jason Williams

Keyword(s):

Breast Reconstruction ◽

Perforator Flap ◽

Rectus Abdominis ◽

Musculocutaneous Flap ◽

Autologous Breast Reconstruction ◽

History Of ◽

Deep Inferior Epigastric Perforator

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The PAP Flap Breast Reconstruction: A Practical Option for Slim Patients

Journal of Reconstructive Microsurgery ◽

10.1055/s-0041-1727200 ◽

2021 ◽

Author(s):

Taehee Jo ◽

Dong Nyeok Jeon ◽

Hyun Ho Han

Keyword(s):

Donor Site ◽

Wound Dehiscence ◽

Diep Flap ◽

Separate Analysis ◽

Flap Reconstruction ◽

Average Body Mass Index ◽

Deep Inferior Epigastric Perforator ◽

Average Body Mass ◽

Artery Perforator ◽

Average Body

Abstract Background The posterior thigh-based profunda artery perforator (PAP) flap has been an emerging option as a secondary choice in breast reconstructions. However, whether a PAP flap could consistently serve as the secondary option in slim patients has not been investigated. Methods Records of immediate unilateral breast reconstructions performed from May 2017 to June 2019 were reviewed. PAP flap breast reconstructions were compared with standard deep inferior epigastric perforator (DIEP) flap breast reconstructions, and were grouped into single or stacked PAP flaps for further analysis. Results Overall, 43 PAP flaps were performed to reconstruct 32 breasts. Eleven patients underwent stacked PAP flap reconstruction, while 17 patients underwent 21 single PAP flap reconstruction. The average body mass index (BMI) of the patients was 22.2 ± 0.5 kg/m2. The results were as follows: no total loss, one case of venous congestion (2.3%), two donor site wound dehiscence cases (4.7%), and one case of fat necrosis from partial flap loss (2.3%). When compared with 192 DIEP flap reconstructions, the final DIEP flap supplied 98.1 ± 1.7% of mastectomy weight, while the final PAP flap supplied 114.1 ± 6.2% of mastectomy weight (p < 0.005), demonstrating that PAP flaps can successfully supply final reconstruction volume. In a separate analysis, single PAP flaps successfully supplied 104.2% (84.2-144.4%) of mastectomy weights, while stacked PAP flaps supplied 103.7% (98.8-115.2%) of mastectomy weights. Conclusion In our series of PAP flap reconstructions performed in low-to-normal BMI patients, we found that PAP flaps, as single or stacked flaps, provide sufficient volume to reconstruct mastectomy defects.

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