The Deep Inferior Epigastric Perforator Learning Curve in the Current Era.

BACKGROUND: Over the last 2 decades, the deep inferior epigastric perforator (DIEP) flap has gained significant popularity in breast reconstruction. However, for some, the increased technical difficulties associated with DIEP breast reconstruction can be a discouraging factor in adopting this technique. There has been a trend in the literature to acknowledge an acute learning curve in the adoption of DIEP breast reconstruction but little evidence to support its ongoing relevance to surgeons who gain significant exposure in training. METHODS: We test the learning curve concept on the senior author's series of 214 DIEP and superficial inferior epigastric artery flaps in a single-surgeon, retrospective study analyzing chronological trends in complication rates both major (total and partial flap loss, reexploration) and minor (fat necrosis, donor site hernia and bulge). RESULTS: The total complication rate was 7.9%, including 1 (0.5%) partial and 1 (0.5%) total flap failure. A comparison of complication rates in the initial 30 flaps in comparison to the remainder of the series revealed no significant difference in major complications (3.3% vs 3.3%, P = 1.00) or minor complications (6.7% vs 4.3%, P = 0.635). Linear-by-linear analysis performed on chronologically ordered groups of 30 flaps revealed no statistically significant trends over the series. CONCLUSIONS: The learning curve associated with the DIEP is complex and likely relates to competency gained in both technical and decision-making aspects of breast reconstruction. This series has demonstrated that with adequate training and an algorithmic approach to DIEP breast reconstruction, eliminating the early learning curve and improving early outcomes are possible.

Distal profunda femoris artery perforator island flap for distal thigh and knee reconstruction: a CT-based anatomical analysis and a case-series study.

BACKGROUND: Locoregional flap options for reconstructing defects of the anterolateral distal thigh/knee region are limited. The distal profunda artery perforator island (PAPI) flap is a local fasciocutaneous propeller-type flap that utilizes the most distal perforator of the profunda femoris artery. The aim of this study is to conduct a CT-based angiographic analysis of the perforator system of the profunda femoris artery and present outcomes on the application of the PAPI flap in the management of post-oncologic defects of the distal thigh and knee. METHODS: CT angiograms were utilized on the lower limbs of 25 healthy patients (mean age, 57 years; 76% male) and the number and location of septocutaneous perforators with a diameter greater than 1 mm were measured. A case series of patients undergoing reconstruction of post-ablative defects which involved the anterolateral and posterior knee performed by the senior author were reviewed. RESULTS: CT angiography demonstrated a robust collection (mean 3.5, range 2 to 5) of septocutaneous perforators from the profunda femoris artery with the most distal perforator located 3.3 cm from the superior patella border. The PAPI flap was successfully used in 10 patients (6F; 4M; mean age 60.6 years; range 30 to 88 years) with a mean defect size of 87.5 cm2 (range 48 to 150 cm2 ). Hand-held Doppler was used to detect the perforator. No flap loss was encountered, and no knee function limitation was noted at follow-up. Minor complications include seroma (1) and intra-articular infection (2). CONCLUSIONS: We conclude that the distal PAPI flap is a reliable and versatile flap that has potentially wide applications.

The Lymphatic Response to Injury with Soft-Tissue Reconstruction in High-Energy Open Tibial Fractures of the Lower Extremity.

BACKGROUND: Severe compound tibial fractures are associated with extensive soft-tissue damage, resulting in disruption of lymphatic pathways that leave the patient at risk of developing chronic lymphedema. There are limited data on lymphatic response following lower limb trauma. Indocyanine green fluorescence lymphography is a novel, real-time imaging technique for superficial lymphatic mapping. The authors used this technique to image the superficial lymphatic vessels of the lower limbs in patients with severe compound tibial fracture. METHODS: Baseline demographics and clinical and operative details were recorded in a prospective cohort of 17 patients who had undergone bone and soft-tissue reconstruction after severe compound tibial fracture between 2009 and 2014. Normal lymphatic images were obtained from the patients' noninjured limbs as a control. In this way, the authors investigated any changes to the normal anatomy of the lymphatic system in the affected limbs. RESULTS: Of the 17 patients, eight had free muscle flaps with split-thickness skin grafting, one had a free fasciocutaneous flap, one had a full-thickness skin graft, six had local fasciocutaneous flaps, and one had a pedicled gastrocnemius flap. None of the free flaps demonstrated any functional lymphatic vessels; the fasciocutaneous flaps and the skin graft demonstrated impaired lymphatic vessel function and dermal backflow pattern similar to that in lymphedema. Local flaps demonstrated lymphatic blockage at the scar edge. CONCLUSION: Severe compound fractures and the associated soft-tissue injury can result in significant lymphatic disruption and an increased risk for the development of chronic lymphedema.

A biodegradable polyurethane dermal matrix in reconstruction of free flap donor sites: a pilot study.

We have developed a biodegradable temporizing matrix (BTM) capable of supporting secondary split-skin graft-take in animal studies. We report its first long-term implantation and use as a dermal scaffold in humans. This preliminary study assesses its ability to integrate, its ease of delamination, its ability to sustain split-skin graft in complex wounds, the degree of wound contraction, and ultimately the quality of the scar at 1 year postimplantation. Ten patients were recruited, each requiring elective free flap reconstruction. Free flap donor sites created were anterolateral thigh flaps, fibular osseocutaneous flaps, or radial/ulnar forearm (RF/UF) flaps. The BTM was implanted when the flap was detached from its donor site. Dressing changes were performed twice weekly. The time elapsed between implantation and delamination depended on the type of flap and thus the wound bed left. Once integrated, the BTMs were delaminated in theatre, and the surface of the "neodermis" was refreshed by dermabrasion, prior to application of a split-skin graft. The BTM integration occurred in all patients (100% in 6 patients, with 90%, 84%, 76%, and 60% integration in the remainder). Integrated BTM sustained successful graft-take in all patients. Complete take was marred in 2 patients, over areas of BTM that had not integrated and graft application was performed too early. The BTM can be applied into wounds in humans and can integrate, persist in the presence of infection, and sustain split-skin overgrafting, despite the trial group presenting with significant comorbidities.