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 Breast reconstruction with deep inferior epigastric artery perforator flap (DIEP-flap). History of development

2021 ◽  
Vol 8 (3) ◽  
pp. 108-117
Author(s):  
I. S. Duadze ◽  
A. D. Zikiryakhodzhaev ◽  
A. S. Sukhotko ◽  
M. V. Starkova ◽  
F. N. Usov ◽  
...  
Keyword(s):  
Breast Reconstruction ◽  
Perforator Flap ◽  
Free Flaps ◽  
Diep Flap ◽  
Tram Flap ◽  
Reconstruction Method ◽  
Epigastric Artery ◽  
Rehabilitation Period ◽  
Deep Inferior Epigastric Artery ◽  
Breast Reconstructive Surgery

The article is devoted to the actual topic of breast reconstruction with autologous tissues. The article discusses the key stages in the development of breast reconstructive surgery using free flaps using microsurgical techniques. A flap of the anterior abdominal wall, among other techniques, is the method of choice for breast reconstruction today, also because it allows you to achieve the most "natural" result. The authors compares different variants of autologous flaps, describes the advantages of the DIEP flap in comparison with the TRAM flap. Also, special attention is paid to the choice of breast reconstruction method depending on age, constitutional characteristics and the presence of risk factors such as smoking, diabetes mellitus and excess BMI. Analyzing the advantages of breast reconstruction with autograft flaps, the author concludes that there is a higher quality of life and improved outcomes in these patients than in patients who underwent implant-based reconstruction. Based on the literature review, it was found that breast reconstruction with the help of perforating flaps is still an area of innovation and constant progress: research in this area to date is mainly aimed at reducing the morbidity of the donor area and methods for isolating recipient vessels, shortening the rehabilitation period and developing reproducible reconstruction method.

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

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.

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

2019 ◽  
Vol 43 (2) ◽  
pp. 133-138
Author(s):  
Nadine S. Hillberg ◽  
Jop Beugels ◽  
Sander M. J. van Kuijk ◽  
René R. J. W. van der Hulst ◽  
Stefania M. H. Tuinder
Keyword(s):  
Breast Reconstruction ◽  
Medical Center ◽  
Major Complication ◽  
P Value ◽  
Diep Flap ◽  
Level Of Evidence ◽  
Recipient Site ◽  
Ischemia Time ◽  
Flap Loss ◽  
Major Complications

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.

Postoperative Free Flap Breast Protocol Optimizing Resources and Patient Safety

2020 ◽  
Vol 36 (05) ◽  
pp. 379-385 ◽  
Author(s):  
Darya Fadavi ◽  
Allison Haley ◽  
Nima Khavanin ◽  
Franca Kraenzlin ◽  
Tobias J. Bos ◽  
...  
Keyword(s):  
Breast Reconstruction ◽  
Hospital Discharge ◽  
Failure Rate ◽  
Cost Savings ◽  
Reoperation Rate ◽  
Hospital Length Of Stay ◽  
Diep Flap ◽  
Complication Rates ◽  
Icu Admission ◽  
Flap Failure

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.

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.

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

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.

Safety of Coupled Arterial Anastomosis in Autologous Breast Reconstruction

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.

scholarly journals 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

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.

Immediate Bilateral Breast Reconstruction Using Abdominally Based Flaps: An Analysis of the Nationwide Inpatient Sample Database

2019 ◽  
Vol 35 (08) ◽  
pp. 594-601 ◽  
Author(s):  
Kathleen A. Holoyda ◽  
Andrew M. Simpson ◽  
Xiangyang Ye ◽  
Jayant P. Agarwal ◽  
Alvin C. Kwok
Keyword(s):  
Postoperative Complications ◽  
Breast Reconstruction ◽  
Nationwide Inpatient Sample ◽  
Free Flaps ◽  
Hospital Charges ◽  
Single Type ◽  
Bilateral Mastectomy ◽  
Complication Rates ◽  
Total Cost ◽  
Nationwide Inpatient Sample Database

Abstract Background Bilateral mastectomy rates are increasing in the United States. The abdomen is the most common harvest site for autologous reconstruction. Nationwide data were examined to determine differences in hospital charges, length of stay (LOS), and early postoperative complications following immediate bilateral pedicled transverse rectus abdominis myocutaneous (pTRAM), free TRAM (fTRAM), deep inferior epigastric perforator (DIEP), and superficial inferior epigastric artery (SIEA) perforator flaps and were compared with unilateral reconstruction. Methods Patients who underwent immediate bilateral breast reconstruction using a single method of abdominally based reconstruction were identified using the 2009 to 2014 Nationwide Inpatient Sample Database. Outcomes included total hospital charges, LOS, and immediate postoperative complications. Results We identified 13,348 cases of bilateral mastectomy with a single type of immediate bilateral autologous flap reconstruction. The majority were bilateral DIEP flaps. Mean total cost for bilateral pTRAM, fTRAM, DIEP, and SIEA flaps was US $21,886.80, US $28,839.40, US $30,051.30, and US $33,784.90, respectively (p < 0.0001). Mean LOS for bilateral pTRAM, fTRAM, DIEP, and SIEA was 4.3, 4.9, 4.5, and 5.4 days, respectively (p = 0.0002), and hematoma rates were 1.93, 2.61, 3.68, and 16.59%, respectively, (p = 0.0001), whereas return to the operating room for vascular anastomosis revision was 0, 1.63, 1.99, and 19.07%, respectively (p < 0.0001). Cost is less for unilateral pTRAM, fTRAM, and DIEP flaps (p < 0.0001). LOS is shorter for unilateral fTRAM versus bilateral (p < 0.0001). No differences were appreciated between unilateral and bilateral hematoma and reoperation rates for any reconstruction (p > 0.1). Conclusion Immediate complication rates were higher in bilateral free flaps compared with bilateral pedicled flaps. pTRAM and fTRAM flap reconstructions are still performed frequently with acceptable immediate results without considering long-term morbidity, aesthetics, and abdominal muscle function. Bilateral SIEA free flaps were associated with significantly higher total cost, LOS, and complication rates compared with other groups. Complications were similar between unilateral and bilateral reconstruction procedures. While cost is significantly greater for bilateral procedures compared with unilateral pTRAM, fTRAM, and DIEP flaps, it is not doubled.

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