The value of microvascular breast reconstruction: Cost equivalence of TRAM and DIEP flaps implications in the era of CMS reforms.

BACKGROUND: Recent CMS billing changes have raised concerns about insurance coverage for deep inferior epigastric perforator (DIEP) flap breast reconstruction. This study compared the costs and utilization of transverse rectus abdominis myocutaneous (TRAM), DIEP, and latissimus dorsi (LD) flaps in breast reconstruction. METHOD: The study utilized the National Inpatient Sample database to identify female patients who underwent DIEP, TRAM, and LD flap procedures from 2016 to 2019. Key data such as patient demographics, length of stay, complications, and costs (adjusted to 2021 USD) were analyzed, focusing on differences across the flap types. RESULTS: A total of 17,770 weighted patient encounters were identified, with the median age being 51. The majority underwent DIEP flaps (73.5%), followed by TRAM (14.2%) and LD (12.1%) flaps. The findings revealed that DIEP and TRAM flaps had a similar length of stay (LOS), while LD flaps typically had a shorter LOS. The total hospital charges to costs using cost-to-charge ratio were also comparable between DIEP and TRAM flaps, whereas LD flaps were significantly less expensive. Factors such as income quartile, primary payer of hospitalization, and geographic region significantly influenced flap choice. CONCLUSION: The study's results appear to contradict the prevailing notion that TRAM flaps are more cost-effective than DIEP flaps. The total hospital charges to costs using cost-to-charge ratio and hospital stays associated with TRAM and DIEP flaps were found to be similar. These findings suggest that changes in the insurance landscape, which may limit the use of DIEP flaps, could undermine patient autonomy while not necessarily reducing healthcare costs. Such policy shifts could favor less costly options like the LD flap, potentially altering the landscape of microvascular breast reconstruction.

First standardized assessment of perforators and perforasomes of the occipital artery - An anatomical study.

BACKGROUND: Flaps have become an integral part of plastic and reconstructive surgery. The robust blood supply of such flaps is a prerequisite to reduce flap failure. Despite the reported versatility of the occipital flap, comprehensive anatomical studies on its perforators and perforasomes are lacking. Hence, we examined the perforators originating from the occipital artery and their associated perforasomes, aiming to fill this knowledge gap for reconstructive surgery techniques. METHODS: 39 of 40 occipital arteries of 20 fresh anatomical head specimens were dissected. Perforators with a least an outer diameter of 0.50 mm were identified and injected with dye to color their respective perforasomes. Location and size of the colored skin areas were determined as well as the location of their perforators were documented and analyzed. RESULTS: In total, 183 perforators were found and described. The mean diameter of these vessels was 0.88 ± 0.27 mm (0.5-2.1 mm). The mean area of the perforasomes was 1288.26 ± 662.51 mm2 (144.60-3890.60 mm2). They were localized over the whole nuchal and occipital area. Lastly, perforator diameters were significantly associated with the size of their resulting perforasomes. CONCLUSION: This study is the first comprehensive overview of perforators and associated perforasomes of the occipital artery on a respectable amount of specimen. The arterial supply of big portions of the occipital and nuchal area is provided solely by the perforators of the occipital artery. For flap surgery, perforator diameter is a crucial detail to be considered in the decision-making process.

A simplified classification and economical application of anterolateral thigh flap.

BACKGROUND: Anterolateral thigh (ALT) flaps have several anatomical variations and clinical uses. Here, a simplified classification and economical application are introduced. METHODS: A total of 168 ALT flap reconstructions performed between January 2013 and December 2016 were reviewed. Vascular anatomy of the flaps was classified into 5 types: type I (single perforator from the transverse branch), type II (single perforator from the descending branch), type III (multiple perforators from the transverse branch), type IV (multiple perforators from the descending branch), and type V (multiple perforators from both branches). Furthermore, flaps harvested via preservation of the proximal perforator were compared with those that were not. RESULTS: Vascular classification revealed that type IV (50.0%) and type V (32.1%) flaps were the most commonly used. Of these, 50.0% of type IV and 79.6% of type V were harvested as proximal-perforator-preserving distal ALT flaps. The proximal-perforator-preserving group had a smaller flap size (104.4 ± 84.3 cm2 versus 145.9 ± 94.1 cm2, p = 0.003), shorter reconstruction time (266.3 ± 76.1 min versus 302.0 ± 103.0 min, p = 0.013), and fewer donor-site complications (2.4% versus 13.3%, p = 0.009) than the traditional group, whereas the flap success rate was comparable (96.5% versus 96.4%) between them. Five cases received a second ALT flap from the same donor site after 3 failures and 2 metachronous defects. CONCLUSIONS: Multiple perforators in ALT flaps allow the harvesting of 2 ALT flaps from the same donor-site metachronously. Our classification and applications can improve efficiency while reducing donor-site morbidity.

Surgeon-conducted color Doppler ultrasound deep inferior epigastric artery perforator mapping: A cohort study and learning curve assessment.

BACKGROUND: Perforator mapping using diagnostic methods facilitates deep inferior epigastric perforator (DIEP) flap planning. Computed tomographic angiography (CTA) is a well-proven tool for perforator mapping. However, the benefits of color Doppler ultrasonography (CDU) are as follows: 1) CDU involves dynamic real-time examination and 2) does not use radiation. Comparing the accuracies of both methods in a cohort of patients, this study aimed to evaluate the learning curve of surgeon-conducted CDU perforator mapping. METHODS: Twenty patients undergoing DIEP flap breast reconstruction were enrolled in a cohort study. All patients underwent CTA perforator mapping preoperatively. XY coordinates of significant perforators were subtracted by a radiologist. A single surgeon (sonographer) with minimal experience with CDU performed CDU perforator mapping, including XY coordinates subtraction. The sonographer was blinded to the CTA data. The reference coordinates of dissected perforators were measured during surgery. Deviations from reference coordinates for both methods were compared, and CDU mapping learning curve was assessed using Joinpoint Regression. RESULTS: We included 20 women (32 DIEP flaps and 59 dissected perforators). The mean deviation between mapped and reference coordinates was 1.00 (0.50-1.12) cm for CDU and 0.71 (0.50-1.12) cm for CTA. The learning curve of CDU mapping showed the breaking point after the seventh patient (≈ 21 localized perforators). After the breaking point, no significant differences between the deviations of both methods were found (p = 0.980). CONCLUSION: A limited number of examinations were needed for the surgeon to learn CDU DIEA perforator mapping with accuracy similar to that of CTA mapping.

Utility of preoperative colour flow Doppler assessment of perforator anatomy in medial sural artery perforator (MSAP) free flaps.

PURPOSE: It is known that the vascular perforators upon which the medial sural artery perforator (MSAP) flap is based are subject to considerable variation. This study seeks to evaluate the use of colour flow Doppler (CFD) as an imaging technique to establish the presence of suitable vessels, the discriminatory findings from that imaging, the rate of flap abandonment and flap complications. METHODS: All patients undergoing MSAP in our institution since 2015 had a pre-operative CFD using a standardised technique. A prior group of 22 patients not having CFD acted as a control group. Data were  collected prospectively. RESULTS: Fourteen patients had CFD. In one patient, no suitable vessels were found. In 13 patients, vessels of suitable size and position were identified, which then correlated precisely with operative findings. Three had suitable vessels in one leg only. No flaps in the CFD group were abandoned. One flap in the CFD group was partially lost. One flap in the prior control group was abandoned. CONCLUSIONS: CFD provided reliable discriminatory information to decide on flap suitability/which leg and correlated precisely with operative findings, with no flap abandonment. Flap survival rate was very high.

Preoperative high-frequency color Doppler ultrasound assessment of the blood vessels of the fibular myocutaneous flap.

OBJECTIVE: The fibular myocutaneous flap is a classic flap used to reconstruct oral and maxillofacial defects. This study aimed to evaluate the effectiveness of high-frequency color Doppler ultrasound in detecting the blood vessels in the fibular myocutaneous flap, analyze the influence of variations in the peroneal vessels and perforating peroneal arteries on the surgical design, and explore the value of this technology in preoperatively assessing the blood vessels of the fibular myocutaneous flap. METHODS: Twenty-five patients with mandibular disease or defect underwent preoperative evaluation of the blood vessels of the calf by high-frequency color Doppler ultrasound. The inner diameter and peak systolic velocity (PSV) of the peroneal arteries and veins and the perforating peroneal arteries were compared between different groups. The consistency between the perforating peroneal arteries marked by ultrasonography and the intraoperative findings was analyzed. RESULTS: The initial segment of the peroneal artery had a larger inner diameter (p<0.001) and lower PSV (p<0.05) than the middle segment. The perforating peroneal arteries were mainly distributed in the middle of the fibula. The inner diameter of the perforating peroneal artery was larger in men than in women (p<0.05). In comparison with surgical exploration as the gold standard, high-frequency color Doppler ultrasound results showed good consistency (Kappa=0.684, 95% CI: 0.512-0.856, p<0.001), with a sensitivity of 89.36%, specificity of 78.57%, and accuracy of 85.33%. CONCLUSION: High-frequency color Doppler ultrasound can detect, quantitatively evaluate, and accurately mark the peroneal artery and vein and perforating peroneal artery before fibular myocutaneous flap transplantation.

Cost-volume analysis of deep inferior epigastric artery perforator flaps for breast reconstruction in the United States.

BACKGROUND: Deep inferior epigastric artery perforator flaps are increasingly utilized over other autologous methods of breast reconstruction. We evaluated the relationship between annual hospital volume and costs after breast reconstruction with the deep inferior epigastric artery perforator flap. METHODS: All female patients undergoing elective implant or autologous tissue breast reconstruction were identified using the 2016-2019 Nationwide Readmission Database. Annual hospital volume of deep inferior epigastric artery perforator reconstructions was tabulated and modeled using restricted cubic splines. Institutions were categorized into high- and low-volume based on the inflection point of the spline between annual caseload and costs. The association between high volume status and costs, complications, length of stay, and 30-day nonelective readmission was assessed using multivariable regression. RESULTS: Of an estimated 94,524 patients meeting inclusion criteria, 33,046 (34.6%) underwent deep inferior epigastric artery perforator flap reconstruction. Deep inferior epigastric artery perforator flap utilization increased from 31% in 2016 to 40% in 2019 (P < .001) among inpatient breast reconstructions. High-volume hospitals more frequently performed bilateral reconstructions (43.3 vs 37.7%, P = .021) but had similar rates of concurrent mastectomy (28.7 vs 30.6%, P = .46), relative to low-volume hospitals. The median cost of deep inferior epigastric artery perforator reconstruction was lower ($29,900 [interquartile range: 22,400-37,400] vs $31,600 [interquartile range: 22,500-44,900], P = .036) at high-volume hospitals compared to low-volume. On adjusted analysis, high-volume status was associated a $3,800 (95% confidence interval: -6,200 to -1,400) decrement in hospitalization costs, and reduced odds of perioperative complications (adjusted odd ratio: 0.68 95% confidence interval: 0.54-0.86). High-volume status was not associated with length of stay or likelihood of unplanned readmission. CONCLUSION: The present study demonstrated an inverse cost-volume relationship in deep inferior epigastric artery perforator flap breast reconstruction. In line with goals of value-based health care delivery, our findings may inform referral patterns to suitable centers for deep inferior epigastric artery perforator breast reconstruction.

A cost-effectiveness analysis of delayed breast reconstruction with pedicled flaps from the back.

BACKGROUND: Variability in breast reconstruction methods provides an opportunity to investigate whether a method is superior to another with regard to cost, quality, or both. We performed a cost-effectiveness analysis (CEA) study based on tertiary endpoint data from a randomized clinical trial to compare the cost-effectiveness of delayed breast reconstruction by either a latissimus dorsi flap (LD) or a thoracodorsal artery perforator flap (TAP). MATERIAL & METHODS: A total of 50 women were included for unilateral delayed breast reconstruction and were randomized to reconstruction by either the LD flap (n = 18) or the TAP flap (n = 22). The CEA was based on differences in shoulder function after the reconstruction. Direct and indirect costs relating to the two procedures were assessed by the Danish Diagnosis-Related Groups tariffs. RESULTS: Our analysis showed a significant positive effect of introducing the TAP flap on the total shoulder score with an additional cost of $2779. The incremental cost-effectiveness ratio was $4481 and based on a willingness to pay (WTP) $500, we found an estimated net benefit of $519, which was statistically significant (p = 0.0375). The cost-effectiveness acceptability curve indicated that there is a 96.3% probability for the TAP flap being cost-effective to the LD flap at a WTP threshold of $500. CONCLUSION: From a societal perspective, our cost-effective analysis demonstrated that the TAP flap is the more cost-effective method of breast reconstruction compared to the LD flap with respect to patient-reported shoulder-related disability.

Preoperative computed tomography assessment for a deep inferior epigastric perforator (DIEP) flap: a new easy technique from the Bologna experience.

BACKGROUND: Deep inferior epigastric perforator (DIEP) flap reconstruction is the gold standard reconstructive technique for women undergoing breast cancer surgery. A preoperative computed tomography angiography (CTA)-dedicated protocol and 3D reconstructions are mandatory for correct surgical planning. PURPOSE: To evaluate the diagnostic performance of a new preoperative CTA protocol and a new reconstruction method in the assessment of DIEP technique. MATERIAL AND METHODS: A total of 263 women (median age 49 years, age range 26-73 years) underwent preoperative CTA examination before DIEP flap breast reconstruction. A CTA-dedicated protocol followed by 3D-reconstructions were performed. Identification, branching pattern, and caliber at origin were assessed for each perforator. Intraoperative findings were the standard of reference. The sensitivity, positive predictive value, and diagnostic accuracy of the preoperative CTA protocol were calculated. RESULTS: In 255/263 (97%) patients, the dominant perforators assessed by CTA resulted adequate for surgical reconstruction. In 260/263 (99%) cases, the imaging localization of the dominant perforators corresponded with those seen intraoperatively (mean errors ≤1 cm). The preoperative CTA imaging sensitivity, positive predictive value, and diagnostic accuracy in determining the localization of perforators were 99% (95% CI 98-100), 100% and 99% (95% CI 98-100), respectively. No statistically significant differences were found between the CTA findings and the surgical findings for the assessment of branching pattern and caliber of the dominant perforators (P < 0.001). CONCLUSION: The present protocol has demonstrated high accuracy in the CTA imaging assessment of the perforators before DIEP flap reconstruction with high reproducibility between CT and surgical findings.

Intraoperative Assessment of DIEP Flap Breast Reconstruction Using Indocyanine Green Angiography: Reduction of Fat Necrosis, Resection Volumes, and Postoperative Surveillance.

BACKGROUND: This study aims to characterize the effect of laser-assisted indocyanine green fluorescence angiography on fat necrosis and flap failure in deep inferior epigastric artery perforator (DIEP) flap breast reconstruction. METHODS: A retrospective review was performed on 1000 free flaps for breast reconstruction at a single center from 2010 to 2017. Indocyanine green angiography was used after completion of recipient-site anastomoses to subjectively assess for areas of hypoperfusion. A multivariable logistical analysis was conducted with 24 demographic and surgical factors and their effects on fat necrosis and flap failure. RESULTS: Five hundred six DIEP flaps were included in the statistical analyses. Thirteen percent of flaps had fat necrosis. Indocyanine green angiography was used for 200 flaps and was independently associated with a decrease in the odds of fat necrosis (OR, 0.38; p = 0.004). There was no reduction in flap failure rates when using indocyanine green angiography (OR, 1.15; p = 0.85). However, there was a decrease in flap loss with increasing venous coupler diameter (OR, 0.031 per 1-mm increase; p = 0.012). The 84.9-g higher weight of resected tissue before inset without indocyanine green angiography versus the weight of the tissue resected with indocyanine green angiography was statistically significant (p = 0.01). Per single incident of fat necrosis, our cohort underwent an additional 0.69 revision procedures, 1.22 imaging studies, 0.77 biopsies, and 1.7 additional oncologic office visits. CONCLUSION: Intraoperative indocyanine green fluorescence angiography decreases the odds of fat necrosis, saves volume when flap trimming at inset, and can significantly reduce the postoperative surveillance burden in DIEP-based breast reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Postoperative Free Flap Breast Protocol Optimizing Resources and Patient Safety.

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.

Flap warming improves intraoperative indocyanine green angiography (ICGA) assessment of perfusion. An experimental study.

BACKGROUND: Indocyanine green angiography (ICGA) is slowly replacing conventional methods of evaluating perfusion during flap surgery. Microcirculatory changes during flap elevation create a marked state of hypoperfusion intraoperatively leading to ICGA underestimation of tissue viability and consequent resection of viable tissue. We propose a novel method of flap warming to induce maximum vasodilation before performing ICGA to increase accuracy in assessing perfusion. METHODS: Submental flaps harvested on a single perforator were created in 8 pigs. ICG angiography was performed in the intraoperative phase (ICGA-C), after inducing maximum vasodilatation by warming the flap at 42 °C (ICGA-W) and at 24H postoperative (ICGA-24). By setting a fluorescence threshold of 33% as indicative of necrosis, the flap surface deemed viable by ICGA was measured for ICGAC, ICGAW and ICGA24. The results were then compared to the actual flap survival observed clinically at 7 days. RESULTS: The mean of ICG-C predicted flap survival (FS-C = 49.17%) is 12.97% lower than the mean of actual flap survival on postoperative day 7 (FS = 62.14%). The mean difference between ICG-W and ICG-24 predicted flap survival (FS-W and FS-24) and actual flap survival in the postoperative day 7 (FS) is lower, 3.13% and 2.15%, respectively. Average perfusion recovery over 24 h was 10.83% (FS-24-FS-C). CONCLUSIONS: Conventional intraoperative ICGA underestimated perfusion in all cases. Warming the flap intraoperatively and achieving maximum vasodilation mitigates the effects of vasoconstriction and mimics the microcirculatory environment encountered at 24 h. Performing angiography after induced vasodilation improves ICGA assessment of flap perfusion.

[Colgajo DIEP como primera opción de reconstrucción mamaria en pacientes mexicanas con cicatrices abdominales previas]. / DIEP flap as a first option for breast reconstruction in Mexican patients with previous abdominal scars.

INTRODUCTION: For many years the abdominal region has been a reliable donor of abundant well-perfused tissue. The subdermal plexus constitutes an intricate network of microvessels that comprise the entire abdominal skin and allow for innumerable and redundant connections. METHOD: Using a retrospective cohort study, we considered the first 100 deep inferior epigastric perforator (DIEP) flaps performed for breast reconstruction in the High Specialty Medical Department #21 of the Mexican Institute of Social Security in Monterrey, Nuevo Leon, Mexico, from January 2010 until December 2015. RESULTS: Of the 100 patients studied, 70 (70%) correspond to the group with abdominal scars and 30 (30%) to the group with no abdominal scars. Of the total patients, only one case of flap necrosis arose secondary to venous thrombosis (1%). This patient had no abdominal scars. The success of the flap was compared between groups using the Fisher exact test, obtaining p = 0.717. CONCLUSION: Abdominal scars do not represent a contraindication for breast reconstruction with DIEP flap even if perforator detection is performed only with hand held 8 MHz doppler.

INTRODUCCIÓN: Durante muchos años, la región abdominal ha sido donadora de abundante tejido bien perfundido basado en el plexo subdérmico, el cual constituye una red intrincada de microvasos que se distribuyen en toda el área de la piel de la pared de dicha región. MÉTODO: Mediante una cohorte retrospectiva, se tomaron en cuenta los primeros 100 colgajos abdominales basados en la arteria epigástrica inferior profunda (DIEP, deep inferior epigastric perforator) para reconstrucción mamaria en la Unidad Médica de Alta Especialidad 21 del Instituto Mexicano del Seguro Social, en Monterrey, NL, México, de enero de 2010 a diciembre de 2015. RESULTADOS: De las 100 pacientes estudiadas, 70 (70%) corresponden al grupo con cicatrices abdominales y 30 (30%) al grupo sin cicatrices abdominales previas. Del total de las pacientes, solo se presentó un caso de necrosis del colgajo secundaria a trombosis venosa (1%). Esta paciente no presentaba ninguna cicatriz abdominal previa. El éxito de los colgajos fue comparado entre ambos grupos mediante una prueba exacta de Fisher y se obtuvo una p = 0.717. CONCLUSIONES: Las cicatrices abdominales no representan una contraindicación para la reconstrucción mamaria con colgajo DIEP, siempre y cuando se detecte un vaso perforante permeable con un Doppler vascular de 8 MHz.

Immediate Unilateral Breast Reconstruction using Abdominally Based Flaps: Analysis of 3,310 Cases.

BACKGROUND: The abdomen is the most common area from which tissue is harvested for autologous breast reconstruction. We sought to examine national data to determine the differences in total hospital charges, length of stay (LOS), and early postoperative complications following pedicled transverse rectus abdominis myocutaneous flap (pTRAM), free TRAM (fTRAM), deep-inferior epigastric perforator (DIEP), and superficial inferior epigastric artery perforator (SIEA) flaps. METHODS: The 2009-2013 Nationwide Inpatient Sample Database was used to identify patients who underwent a unilateral mastectomy and only one type of abdominally based autologous flap (pTRAM, fTRAM, DIEP, and SIEA) during the same hospital admission. Outcomes of interest included total charges, LOS, and complications including revision of vascular anastomosis and hematoma. RESULTS: A total of 3,310 cases were identified, corresponding to 15,991 abdominally based unilateral immediate breast reconstructions after standard weighting was applied; 5,079 (31.8%) were pTRAM flaps, 4,461 (27.9%) were fTRAM flaps, 6,206 (38.8%) were DIEP flaps, and 245 (1.5%) were SIEA flaps. The mean total charges for pTRAM, fTRAM, DIEP, and SIEA flaps were $17,765.5, $22,637.6, $25,814.6, and $26,605.2, respectively (p < 0.0001). The mean LOS for pTRAM, fTRAM, DIEP, and SIEA flaps were 96.5, 106.5, 106.7, and 108.9 hours, respectively (p = 0.002). The rates for return to the OR for the revision of a vascular anastomosis for pTRAM, fTRAM, DIEP, and SIEA were 0.0%, 1.72%, 2.66%, and 5.64%, respectively (p < 0.0001). CONCLUSIONS: There is variation in the total charges, LOS, and early complications between pTRAM, fTRAM, DIEP, and SIEA flap-based breast reconstruction. fTRAM, DIEP, and SIEA flaps incur higher hospital total charges, have longer lengths of stay, and experience more immediate complications compared with pTRAM. Well-designed prospective trials are required to better understand the findings from this study with the inclusion of other critical outcomes such as patient satisfaction, aesthetic results, and long-term outcomes such as abdominal wall morbidity.

Colour Doppler sonography in the preoperative assessment of the vascular pedicle from the anterolateral thigh flap: proposal for a mathematical formula to predict pedicle length.

INTRODUCTION: The anterolateral thigh flap (ALT) is one of the most commonly used grafts in head and neck reconstructive surgery. In this type of surgery, it is essential that the vascular pedicle be long enough to ensure proper vascular anastomosis. However, it is difficult to accurately estimate the pedicle length preoperatively. In this context, the current study had two aims: (1) to assess the value of colour Doppler sonography (CDS) in the preoperative assessment of the vascular pedicle and (2) to develop a mathematical model to predict the length of the vascular pedicle based on the ultrasound findings. MATERIALS AND METHODS: Retrospective review of patients who underwent primary surgery for head and neck cancer followed by ALT flap reconstruction at our institution from 2014 to 2018. All patients underwent CDS prior to surgical excision of the flap. RESULTS: Preoperative CDS was useful to identify the location of the vascular perforators, to estimate the pedicle length, and to identify the vascularization variant. Using the proposed mathematical formula, the estimated minimum pedicle length and actual length agreed in 73.9% of cases, increasing to 84.1% when a 5 mm margin of error was allowed. Moreover, preoperative ultrasound accurately distinguished the two anatomical variants of the ALT vasculature in nearly all cases (97.1%). CONCLUSION: This study confirms the value of preoperative colour Doppler sonography for ALT flap reconstruction. The proposed mathematical model provides a highly accurate method of preoperatively assessing the length of the vascular pedicle, which may be of value in head and neck surgery.

A cost-effectiveness analysis of DIEP vs free MS-TRAM flap for microsurgical breast reconstruction.

BACKGROUND AND OBJECTIVES: The deep inferior epigastric perforator (DIEP) flap may be associated with less long-term donor-site morbidity compared with free muscle-sparing transverse rectus abdominis myocutaneous flap (MS-TRAM) flap. However, DIEP flaps may have longer operative time and higher rates of acute postoperative complications. We performed a cost-effectiveness analysis (CEA) that compared the long-term costs and patient-reported outcomes between the two flaps. METHODS: A retrospective cohort of women who received free MS-TRAM or DIEP flap reconstruction between January 2008 and December 2012, with a minimum of 2-year follow-up, were recruited. Cost data of the primary reconstruction and any subsequent hospitalization due to complications from the reconstruction within 2 years were obtained. Each patient received a BREAST-Q questionnaire at 2 years post-reconstruction. RESULTS: In total, 227 patients (180 DIEP, 47 free MS-TRAM) were included. DIEP patients had significantly fewer abdominal hernia (P = 0.04). The adjusted-incremental cost-effectiveness ratios found that DIEP flap was more cost-effective to free MS-TRAM flap in the domains of "Physical Well-Being of the Abdomen" and "Satisfaction with Outcome." CONCLUSIONS: DIEP flap is the more cost-effective method of autologous breast reconstruction in the long-term compared with free MS-TRAM flap with respect to patient-reported abdominal well-being and overall satisfaction with the outcome.

Check the Record: Remote CT Scans for Breast Flap Perforator Mapping.

BACKGROUND: Perforator mapping with computed tomography angiography (CTA) prior to autologous breast reconstruction reduces donor-site morbidity and operative time, but is costly. The aim of this study was to evaluate whether pre-existing CT scans could be used for dominant perforator identification before autologous reconstruction. METHODS: We identified all female patients who underwent mastectomy with immediate or delayed breast reconstruction with abdominal free flaps at a single institution between 2006 and 2016. Medical records were reviewed to identify patients with pre-existing CT scans of the abdomen/pelvis. CT images were reviewed by the senior surgeon and ranked on a 1 to 3 scale to indicate utility for preoperative planning. An analysis was performed to assess financial savings and radiation avoidance associated with the use of pre-existing scans. RESULTS: Of 301 identified patients, 44.9% (n = 135) had an available pre-existing CT. A dominant perforator was identified on 92.6% of scans. A higher proportion of dominant perforators was identified using positron emission tomography (PET)/CT scans compared with CT scans with intravenous (IV) contrast and noncontrast CTs (p < 0.0001). Compared with PET/CTs and CTs with IV contrast, the average utility score for noncontrast CTs was lower (p = 0.0001). Dominant perforators were clearly identified in patients who had both a remote CT scan and a preoperative CTA. Perforator mapping using remote CT scans yielded a projected radiation reduction of 13.2 mGy per patient and yielded a projected annual U.S. health care savings of $28,459,638. CONCLUSION: Our study suggests that pre-existing CT scans represent a viable and economical alternative for perforator mapping before abdominal-based free flap breast reconstruction.

Reliability of Color Doppler Ultrasound Imaging for the Assessment of Anterolateral Thigh Flap Perforators: A Prospective Study of 30 Perforators.

Despite numerous advantages, the anterolateral thigh perforator flap suffers from the variable position and nature of its perforators. The aim of the authors' study was to assess the reliability of preoperative color Doppler ultrasound imaging for the exploration of perforator location and course of anterolateral thigh perforator flaps. A prospective cohort study involving patients for whom head and neck reconstruction was planned with thin anterolateral thigh perforator flaps was conducted. Each patient underwent a color Doppler ultrasound exploration of the thighs, in the operating room, immediately before surgery. The sonographer was the surgeon who raised the flaps. Perforators were sought according to surgical needs, and the same location protocol was followed for all of the cases, using an orthonormal coordinate system to report the passages of the perforators through the vastus lateralis aponeurosis. Between January of 2016 and January of 2017, 22 thin anterolateral thigh perforator flaps were successfully harvested. Thirty perforators were located and used. The median distance between the preoperative color Doppler ultrasound planning and the final location of the perforators was 5 mm, statistically smaller than a 10-mm threshold (p = 0.002). Color Doppler ultrasound effectively predicted the nature of the perforators in 90 percent of the cases. The median duration for perforator color Doppler ultrasound location was 3 minutes, statistically shorter than 10 minutes (p = 0.0001). Preoperative color Doppler ultrasound seems to be reliable, accurate, and compatible with a quick routine assessment during patient setup for the elevation of thin anterolateral thigh perforator flaps. CLINICAL QUESTION/LEVEL OF EVIDENCE: Diagnostic, II.

Predicting and planning for SIEA flap utilisation in breast reconstruction: An algorithm combining pre-operative computed tomography analysis and intra-operative angiosome assessment.

BACKGROUND: Low flap complication rates and excellent aesthetic outcomes are now commonplace in breast reconstruction. As a result, attention is now being focussed on minimising donor site morbidity. Despite its potential donor site advantages, the superficial inferior epigastric artery (SIEA) flap is often discounted, given concerns about the high flap failure rates. In this study, we present our experience of using the SIEA flap in breast reconstruction and provide an algorithm based on pre-operative computed tomography angiography (CTA) to aid pre-operative planning. METHODS: A retrospective analysis of SIEA flap breast reconstruction cases performed at our unit between 2009 and 2016 was performed and outcomes were assessed. In addition, the patients' pre-operative CTA images were assessed and compared to those of a matched group of patients who underwent deep inferior epigastric artery perforator (DIEP) flap breast reconstruction. RESULTS: Twenty-six patients who underwent SIEA flap breast reconstruction were eligible for inclusion. No flaps were lost. Donor site seroma rate was 20%. The largest SIEA diameter in those who underwent an SIEA flap was significantly larger (p = 0.0001) than in those who underwent DIEP flap breast reconstruction. Significantly more number of patients who underwent SIEA flap breast reconstruction had a SIEA diameter greater than or equal to that of the largest DIEP flap perforator (p = 0.0001) in the group where a DIEP flap was used for breast reconstruction. CONCLUSION: High success rates can be achieved with abdominal flaps based on the superficial vascular system and careful pre- and perioperative assessment of patients.