A clinical review of 9 years of free perforator flap breast reconstructions: an analysis of 675 flaps and the influence of new techniques on clinical practice.

The aim of this study is to review our 9-year experience with deep inferior epigastric perforator (DIEP) breast reconstructions to help others more easily overcome the pitfalls we experienced. A chart review was conducted for all 543 patients who had 622 DIEP breast reconstructions in our clinic between January 2000 and January 2009. In this time, there were an additional 28 superior gluteal artery perforator and 25 superficial inferior epigastric artery reconstructions, bringing the total free flap reconstructions to 675. In the early years, the success rate was 90.7%, the average operative time was 7 hours and 18 minutes, and the complication rate was 33.3%; these have improved to 98.2%, 4 hours and 8 minutes, and 19.3%, respectively. We describe our selection criteria, preoperative vascular mapping, surgical techniques, and postoperative monitoring as they relate to these improvements in outcome, operative time, and complications. The DIEP flap is a safe and reliable option in breast reconstructions. By acquiring experience with the flap and introducing new and improving existing techniques we have improved the ease of the procedure and the success rate and have shortened the operative time.

Measuring the pressure in the superficial inferior epigastric vein to monitor for venous congestion in deep inferior epigastric artery perforator breast reconstructions: a pilot study.

During deep inferior epigastric artery perforator (DIEP) flap dissection, we noted that in many cases the superficial vein on the ipsilateral side of the flap was engorged and tense, and in others, it was empty. This led us to believe that the pressure is increased as the result of preferential outflow through the superficial vein in some cases, which could result in venous congestion of the flap if this vessel was not anastomosed. To test this hypothesis, we measured the venous pressure in the superficial venous system before and after flap dissection. The pressure in the superficial inferior epigastic vein of a DIEP flap was measured in 26 consecutive flaps to investigate the correlation between the pressure and venous congestion of the flap. The first measurement was performed at the beginning of the dissection, and the second measurement was taken after the flap had been completely raised on a single perforator. The mean increase in pressure after flap dissection was 10.6 mm Hg (mu = 10.6; range -1 to 31; O +/- 7.0 mm Hg). Clinical signs of venous congestion were observed in one case. In this case, the increase in venous pressure was with 31 mm Hg, also the highest. Although the results of this report are preliminary, they indicate that the pressure in the superficial vein of DIEP flaps might be of predictive value for venous congestion.

Introduction of the implantable Doppler system did not lead to an increased salvage rate of compromised flaps: a multivariate analysis.

BACKGROUND: The Cook-Swartz implantable Doppler system was introduced at the Uppsala University Hospital to ease free flap monitoring and improve salvage rates by an earlier detection of vascular compromise. The aim of the current analysis was to investigate whether the system indeed improved the salvage rate of revisions. METHODS: All cases that needed revision among a consecutive series of patients being monitored with the implantable Doppler system between June of 2006 and January of 2009 were compared with a similar set of patients operated on before the introduction of the implantable Doppler system over an equal time span monitored with conventional methods. Data were extracted from the medical files of the patients. Logistic regression was used to identify factors associated with the outcome of the revision. Values of p < 0.05 were considered statistically significant. RESULTS: A total of 327 flaps were monitored with the implantable Doppler system, of which 35 needed revision. In the control group, 303 flaps were included, of which 40 needed revision. The revision was successful in 69 percent of the cases in the implantable Doppler system group; in the group monitored by only conventional methods, this rate was 60 percent. Univariate analysis showed no statistical difference between these success rates (p = 0.441; odds ratio, 1.455; 95 percent confidence interval, 0.560 to 3.775). Multivariate analysis did not show a statistical difference either (p = 0.799; odds ratio, 1.143; 95 percent confidence interval, 0.410 to 3.182). CONCLUSION: The introduction of the implantable Doppler system did not lead to a significant increase in the salvage rate of revised flaps.

Preoperative CT angiography reduces surgery time in perforator flap reconstruction.

UNLABELLED: The use of perforator flaps in breast reconstructions has increased considerably in the past decade. A disadvantage of the perforator flap is difficult dissection, which results in a longer procedure. During spring 2006, we introduced CT angiography (CTA) as part of the diagnostic work-up in perforator flap reconstructions to visualise each perforator more accurately. The main objectives were to reduce surgery time and the number of complications. A chart review was conducted 1 year after CTA introduction to investigate if these objectives were met. MATERIALS AND METHODS: Patients with a deep inferior epigastric perforator (DIEP) flap who underwent preoperative analysis through CTA were retrospectively evaluated. The population

Early reintervention of compromised free flaps improves success rate.

INTRODUCTION AND AIM: To develop a protocolized monitor schedule in microvascular free flap reconstruction, we investigated a possible correlation between the outcome and the interval between clamp release and start of revision. MATERIALS AND METHODS: All the charts of patients treated between 2000 and 2006 with a free flap were evaluated. The patients who underwent a flap revision were further analyzed. RESULTS: A total of 608 free flaps were evaluated; 69 of these flaps were revised. Most vascular complications took place within the first 24 h; the latest complication was observed 8 days after surgery. After 6 days post surgery, the number of revisions decreased considerably. With regard to the salvaged flaps the mean time to start the revision was 46.5 h (SD 39). With regard to the failed revisions, the mean time to start the revision was 82.0 h (SD 47). This difference proved significant (P = 0.006). CONCLUSION: Our data shows that the majority of anastomotic failures occur within the first 24 h. Thereafter, the frequency of failures decreases. We also found that the time between initial reconstruction and start of the salvage procedure influences the outcome of the revision negatively.