Robotic Repair: An Alternative Technique for Rectus Diastasis and Abdominal Bulge Following DIEP Flap Breast Reconstruction.

BACKGROUND: The deep inferior epigastric artery perforator (DIEP) flap is the gold standard in autologous breast reconstruction. Despite advances in perforator dissection, abdominal morbidity still occurs. Traditional rectus diastasis (RD), abdominal bulge, and hernia repair with open techniques are associated with higher complication rates and recurrence. OBJECTIVES: We present a novel case series of robotic repair of symptomatic RD and/or abdominal bulge with concurrent hernia following DIEP flap surgery. METHODS: A single-center, retrospective review was conducted of 10 patients who underwent bilateral DIEP flap breast reconstruction and subsequent robotic repair of RD and/or abdominal bulge and hernia. Preoperative demographics and postoperative clinical outcomes were reviewed. RD up to 5 cm, abdominal bulge, and any concurrent ventral/umbilical hernias were repaired robotically with retrorectus plication and macroporous mesh reinforcement. RESULTS: The average age and BMI were 49 years (range 41-63) and 31 kg/m2 (range 26-44), respectively. The average number of perforators harvested per flap was 2.5 (range 1-4). Average RD and hernia size were 3.95 cm (range 2-5) and 5.8 cm2 (1-15), respectively. Eight patients stayed 1 night in the hospital, and 2 went home the same day as the robotic repair. No patients were converted to open technique and none experienced complications within 30 days. CONCLUSIONS: For patients who experience donor site morbidity following DIEP flap breast reconstruction, minimally invasive robotic repair of RD and/or abdominal bulge with hernia can be performed with mesh reinforcement. This technique is effective, with low complication rates, and should be considered over open repair.

Microsurgical breast reconstruction and primary hypercoagulable disorders.

BACKGROUND: Primary hypercoagulable disorders pose a significant challenge to microsurgeons and have traditionally been regarded as a relative contraindication to free tissue transfer. Since free flaps offer numerous advantages in breast reconstruction, there is an effort to expand the population to whom these operations can be safely offered. The purpose of this study is to describe our chemoprophylaxis regimen in cases of primary hypercoagulability, as well as to compare flap outcomes and complications between women with and without hypercoagulability. PATIENTS AND METHODS: A single institution retrospective review identified 15 patients (25 flaps) with known primary hypercoagulability who underwent microsurgical breast reconstruction from 2010 through 2020. There were 785 patients (1268 flaps) without primary hypercoagulability who underwent microsurgical breast reconstruction, including 40 patients (73 flaps) with a history of venous thromboembolism (VTE), evaluated for comparison. Patient characteristics, thromboprophylaxis regimen, and surgical outcomes were collected. In carrying out this cohort study, we have adhered to Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines. RESULTS: Fifteen patients with primary hypercoagulability were identified, including heterozygous factor V Leiden mutation (n = 12), protein S deficiency (n = 1), prothrombin mutation (n = 1), and primary antiphospholipid syndrome (n = 1). Thirteen of these (87%) were discharged with an extended LMWH course. There was no postoperative VTE or mortality in this cohort, and no significant difference in hematoma or transfusion compared with the control group (p = .31, p = .87, respectively). The flap loss rate was 4% in the hypercoagulable group compared with 0.92% in the control group (p = .15). The salvage for arterial or venous compromise in the hypercoagulable group was poor (0% vs. 52%, p = .3). CONCLUSION: Microsurgical breast reconstruction in women with primary hypercoagulability disorders is feasible with acceptable risk of flap loss but poor salvage potential. Postoperative thromboprophylaxis with extended prophylactic LMWH in this population appears to be a safe regimen.