Simultaneous Co-surgeon Deep Inferior Epigastric Perforator (DIEP) Flap Breast Reconstructions: Feasibility and Clinical Outcomes.

BACKGROUND: A co-surgeon model is known to be favorable in microvascular breast reconstruction, but simultaneous co-surgeon deep inferior epigastric perforator (DIEP) flap cases have not been well-studied. The authors hypothesize that performing two simultaneous co-surgeon bilateral DIEP flap reconstructions results in non-inferior clinical outcomes and may improve patient access to care. METHODS: A single-institution, retrospective cohort study was performed utilizing record review to identify all cases of co-surgeon free-flap breast reconstructions over a 38-month period. Patients who underwent simultaneous bilateral DIEP flap breast reconstructions with the same two co-surgeons were identified. The control group consisted of subjects who underwent non-simultaneous reconstruction by the same co-surgeons within the same, preceding, or following month of those in the study group. Primary outcome variables were 90-day postoperative complications, while secondary outcomes were operating time, ischemia time, and length of stay. Descriptive statistics, univariate and multivariable regression analyses were performed. RESULTS: Overall, 137 subjects were identified and 64 met the inclusion criteria (n = 28 study, n = 36 control). There were no statistically significant differences between groups in body mass index, radiation, trainee experience, flap perforator number, immediate/delayed reconstruction, or length of stay. There were also no statistically significant differences in complications, including flap loss, anastomosis revision, take-back to the operating room, or re-admission. Operative time was longer in the simultaneous DIEP group (540.5 vs. 443.5 min, p < 0.01), but ischemia time was shorter in the simultaneous group (64.0 vs. 80.5 min, p < 0.01). CONCLUSIONS: A simultaneous co-surgeon approach to bilateral DIEP flap reconstruction may improve access to care and does not result in a higher complication rate compared with non-simultaneous bilateral DIEP flaps.

MRA for Preoperative Planning and Postoperative Management of Perforator Flap Surgeries: A Review.

Perforator flap magnetic resonance angiography (MRA) has emerged as a widely accepted and preferred modality for perforator flap mapping at several institutions. Autologous perforator flaps are a type of reconstructive microsurgical technique that involves transferring skin and fat from one part of the patient's body to another to replace tissue lost due to trauma, cancer resection, or other reasons. Autologous perforator flaps are based on a specific perforating blood vessel perfusing the transferred tissue. Hence, the surgery relies on the precise identification and mapping of perforating vessels to ensure successful outcomes. With its superior soft tissue contrast and multiplanar imaging capabilities, MRA has shown great potential in providing accurate and detailed visualization of perforator anatomy, size, and course. This review article summarizes the current literature on perforator flap MRA, including its technical considerations, imaging protocols, postprocessing, and reporting, specifically for autologous breast reconstructions. The advantages and limitations of MRA in evaluating perforator flaps are discussed, including its role in preoperative planning, intraoperative guidance, and postoperative assessment. Anatomy, brief surgical technique, specific technical modifications, and reporting of most commonly performed autologous breast flaps are described. Recent advancements in Perforator flap surgery and MRA techniques are discussed. Additionally, we examine the emerging role of artificial intelligence and machine learning in improving the accuracy and efficiency of perforator flap MRA interpretation. LEVEL OF EVIDENCE: 5 TECHNICAL EFFICACY: Stage 5.

Management of a Complex, Recurrent Case of Medial Thigh Sarcoma With Pedicled Deep Inferior Epigastric Artery Perforator (DIEP) Lymphatic Flow-Through (LyFT) Flap and Secondary Anterolateral Thigh (ALT) Free Flap With Innervated Vastus Lateralis Anastomosed to Synthetic Artery Graft: A Case Report.

Soft-tissue sarcomas (STS) are rare solid tumors of mesenchymal cell origin and account for only 1% of adult malignancies. They tend to occur most commonly in the lower extremities. Reconstruction after sarcoma resection can be challenging, especially when important structures are involved and recurrences occur. Additionally, more attention is now being paid to reconstructing the lymphatic system to prevent lymphatic complications. In this case report, we presented the management of recurrent medial thigh sarcoma that necessitated multiple challenging reconstructions to provide valuable insights for lectures on similar cases. A 50-year-old male patient was diagnosed with an undifferentiated pleomorphic cell sarcoma (UPS) of the anteromedial thigh. After preoperative radiotherapy, a mass of 23 × 15 cm was removed, and reconstruction with a pedicled deep inferior epigastric artery perforator (p-DIEP) flap-based lymphatic flow through (LyFT) was performed. Six months later, the patient developed the first local recurrence with the presence of a distant metastasis. Following the tumor resection, the medial part of the DIEP flap was de-epithelized and buried in the defect for dead space obliteration. Another local recurrence arose 7 months after the second surgery. Therefore, a major debulking surgery involving the femoral neurovascular bundle was performed. The femoral artery was reconstructed with a synthetic graft, and the femoral vein with the great saphenous vein harvested from the contralateral thigh. A composite myocutaneous neurotized anterolateral thigh (ALT) flap from the contralateral thigh was used to obliterate the defect and restore the loss of function of the quadriceps femoris. Two lymphaticovenular anastomoses (LVAs) were performed at the ankle to reduce the risk of lymphatic sequelae. This case report highlights the importance of integrating various techniques to create a tailored approach that effectively addresses complex surgical requirements to avoid limb amputation and maintain functionality.

Advancing DIEP Flap Monitoring with Optical Imaging Techniques: A Narrative Review.

OBJECTIVES: This review aims to explore recent advancements in optical imaging techniques for monitoring the viability of Deep Inferior Epigastric Perforator (DIEP) flap reconstruction. The objectives include highlighting the principles, applications, and clinical utility of optical imaging modalities such as near-infrared spectroscopy (NIRS), indocyanine green (ICG) fluorescence angiography, laser speckle contrast imaging (LSCI), hyperspectral imaging (HSI), dynamic infrared thermography (DIRT), and short-wave infrared thermography (SWIR) in assessing tissue perfusion and oxygenation. Additionally, this review aims to discuss the potential of these techniques in enhancing surgical outcomes by enabling timely intervention in cases of compromised flap perfusion. MATERIALS AND METHODS: A comprehensive literature review was conducted to identify studies focusing on optical imaging techniques for monitoring DIEP flap viability. We searched PubMed, MEDLINE, and relevant databases, including Google Scholar, Web of Science, Scopus, PsycINFO, IEEE Xplore, and ProQuest Dissertations & Theses, among others, using specific keywords related to optical imaging, DIEP flap reconstruction, tissue perfusion, and surgical outcomes. This extensive search ensured we gathered comprehensive data for our analysis. Articles discussing the principles, applications, and clinical use of NIRS, ICG fluorescence angiography, LSCI, HSI, DIRT, and SWIR in DIEP flap monitoring were selected for inclusion. Data regarding the techniques' effectiveness, advantages, limitations, and potential impact on surgical decision-making were extracted and synthesized. RESULTS: Optical imaging modalities, including NIRS, ICG fluorescence angiography, LSCI, HSI, DIRT, and SWIR offer a non- or minimal-invasive, real-time assessment of tissue perfusion and oxygenation in DIEP flap reconstruction. These techniques provide objective and quantitative data, enabling surgeons to monitor flap viability accurately. Studies have demonstrated the effectiveness of optical imaging in detecting compromised perfusion and facilitating timely intervention, thereby reducing the risk of flap complications such as partial or total loss. Furthermore, optical imaging modalities have shown promise in improving surgical outcomes by guiding intraoperative decision-making and optimizing patient care. CONCLUSIONS: Recent advancements in optical imaging techniques present valuable tools for monitoring the viability of DIEP flap reconstruction. NIRS, ICG fluorescence angiography, LSCI, HSI, DIRT, and SWIR offer a non- or minimal-invasive, real-time assessment of tissue perfusion and oxygenation, enabling accurate evaluation of flap viability. These modalities have the potential to enhance surgical outcomes by facilitating timely intervention in cases of compromised perfusion, thereby reducing the risk of flap complications. Incorporating optical imaging into clinical practice can provide surgeons with objective and quantitative data, assisting in informed decision-making for optimal patient care in DIEP flap reconstruction surgeries.

The Impact of Scars After DIEP-Flap Breast Reconstruction on Satisfaction and HR-QoL: A Cross-Sectional Study Comparing BREAST-Q Scores.

BACKGROUND: Although deep inferior epigastric perforator (DIEP) flap breast reconstruction is the most widely used technique for autologous breast reconstruction, this technique leads to large scars in visible areas on breast and abdomen. So far, limited studies have thoroughly addressed the impact of breast and abdominal scars on satisfaction and Health-related Quality of Life (HR-QoL). OBJECTIVES: This research aimed to determine whether women with no/minor scar symptoms after undergoing DIEP-flap breast reconstruction differ in satisfaction and perceived HR-QoL from women with symptomatic scars. MATERIALS AND METHODS: In this cross-sectional survey study, women who had previously undergone DIEP-flap breast reconstruction completed an online survey. Patient-reported scar quality was assessed with the Patient and Observer Scar Assessment Scale (POSAS), and satisfaction and HR-QoL with BREAST-Q. Independent-samples t-tests were conducted to compare BREAST-Q scores between women with no/minor scar symptoms (POSAS overall opinion score 1-3) and women with symptomatic scars (POSAS overall opinion score 4-10). RESULTS: A total of 248 women completed the survey. Women with scar symptoms had significantly worse BREAST-Q scores on 'Satisfaction with breasts,' 'Physical well-being,' 'Psychosocial well-being' and, 'Sexual well-being' compared to women with no/minor scar symptoms (p ≤ 0.001). CONCLUSION: After DIEP-flap breast reconstructions, women with symptomatic breast and abdominal scars had a clinically relevant and statistically significant lower degree of satisfaction and HR-QoL compared to women who had no/minor scar symptoms. We therefore recommend to explicitly and repeatedly address inevitability of visible scars after DIEP-flap breast reconstruction, aiming to improve preoperative patient selection and post-operative expectation management. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Anomalous anatomic variation of an absent deep inferior epigastric artery: implications for autologous breast reconstruction.

Autologous breast reconstruction using abdominally based perforator flaps has become increasingly popular following mastectomy for breast cancer. Of these, the deep inferior epigastric artery perforator (DIEP) flap represents one of the most popular techniques. However, surgeons must remain cognizant of anatomic variations in the abdominal wall vasculature that could complicate or preclude planned DIEP flaps. In this case, a 64-year-old female with a history of prior tubal ligations and caesarean sections underwent preoperative computed tomographic angiography (CTA) for planned autologous breast reconstruction with a DIEP flap. CTA revealed complete absence of the left deep inferior epigastric artery, with a sizeable left abdominal wall perforator visualized receiving retrograde flow from a crossing midline branch originating from the contralateral right deep inferior epigastric system. This vessel traversed the midline in a superficial plane in the subcutaneous tissue. Despite this aberrant anatomy, the surgical team successfully raised a unilateral DIEP flap based on the right pedicle. This case represents a unique anatomical variation of the abdominal wall and emphasises the importance of preoperative imaging when planning abdominally based free flaps.

DIEP Flap for Head and Neck Reconstruction: An Underutilized Option!

Background The deep inferior epigastric artery perforator (DIEP) flap is a workhorse flap for breast reconstruction. Its use for head and neck (HN) reconstruction is rare. Abdomen provides a donor site abundant in skin and subcutaneous tissue, amenable to primary closure; sizeable, robust, and consistent perforators and a long, sizeable pedicle for comfortable microvascular anastomosis. Its offers all the donor variables needed for HN reconstruction in abundance. Methods It is a quasiexperimental design study. DIEP flap use for HN reconstruction in our series was opportunistic, that is, when donor site matched the defect. Cases that had very thick thighs and lesser bulk in abdomen and cases that had very thin thighs but much more bulk in abdomen were considered for reconstruction using DIEP flap. Results The DIEP flap was done in 11 cases for HN reconstruction. There were two re-explorations during postoperative period: one flap loss and another had partial necrosis. Conclusion Abdomen is an excellent donor site option for HN reconstruction in selected cases, especially when harvested as a perforator flap.

A systematic review of the scientific evidence of venous supercharging in autologous breast reconstruction with abdominally based flaps.

BACKGROUND: Abdominally based free flaps are commonly used in breast reconstruction. A frequent complication is venous congestion, which might contribute to around 40% of flap failures. One way to deal with it is venous supercharging. The primary aim of this study was to investigate the scientific evidence for the effects of venous supercharging. METHODS: A systematic literature search was conducted in PubMed, CINAHL, Embase, and Cochrane library. The included articles were critically appraised, and certainty of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach. RESULTS: Thirty-six studies were included. Most studies had serious study limitations and problems with directness. Three studies report 'routine' use of venous supercharging and performed it prophylactically in patients who did not have clinical signs of venous congestion. Seventeen studies report on flap complications, of which one is a randomised controlled trial demonstrating statistically significant lower complication rates in the intervention group. The overall certainty of evidence for the effect of a venous supercharging on flap complications, length of hospital stay and operative time, in patients without clinical signs of venous congestion, is very low (GRADE ⊕ ⊕ ⊝ ⊝), and low on and surgical takebacks (GRADE ⊕ ⊕ ⊝ ⊝). Twenty-one studies presented data on strategies and overall certainty of evidence for using radiological findings, preoperative measurements, and clinical risk factors to make decisions on venous supercharging is very low (GRADE ⊕ ⊝ ⊝ ⊝). CONCLUSION: There is little scientific evidence for how to predict in which cases, without clinical signs of venous congestion, venous supercharging should be performed. The complication rate might be lower in patients in which a prophylactic venous anastomosis has been performed. TRIAL REGISTRATION: PROSPERO (CRD42022353591).

Characteristics and distribution of chronic pain after mastectomy and breast reconstruction: a long-term prospective cohort study.

PURPOSE: Chronic pain following breast surgery is a concern for breast cancer survivors; however, few studies have investigated the localization of persistent postoperative pain. We conducted this study to identify the location of pain following breast reconstruction. METHODS: A total of 213 Japanese women undergoing mastectomy only or breast reconstruction with a tissue expander/implant (TE/Imp) or a deep inferior epigastric perforator (DIEP) flap were enrolled in the study. Questionnaires related to pain location were sent to patients at the end of postoperative year (POY) 1 and POY 5. Multiple comparisons of the types of operation and cross-tabulation were made between the two time points. RESULTS: Surveys were completed by 107 of the women. Severe pain in the upper medial breast was significantly more common in POY 1 after DIEP reconstruction than after mastectomy only (P = 0.01), whereas abdominal pain was worse in POY 5 after DIEP reconstruction than after mastectomy only (P = 0.04). Pain in the medial arm and axilla had resolved better after TE/Imp (P = 0.03) and DIEP reconstruction (P = 0.01) than after mastectomy only by POY 5, but the difference between TE/Imp and DIEP reconstruction was not significant. CONCLUSIONS: These results show that localization of prolonged postoperative pain following breast reconstruction differs depending on the surgical strategy.

DIEP flap in breast reconstruction: A morbidity study of bilateral versus unilateral reconstruction.

BACKGROUND: The Deep Inferior Epigastric Perforator (DIEP) flap is a modality in breast reconstruction of choice. Despite its well-documented benefits and complications, a lack of evidence remains with regards to the risks of performing a bilateral versus a unilateral reconstruction. As such, we sought to compare the rates of adverse outcomes in the perioperative and postoperative periods associated with a unilateral versus a bilateral DIEP flap breast reconstruction. METHODS: A retrospective cohort study of 178 consecutive patients undergoing unilateral versus. bilateral deep inferior epigastric perforator flap breast reconstruction was performed at our tertiary care center over a 3-year period. Data on demographics, operative time, intraoperative and postoperative complications, and surgical re-exploration, were extracted for both groups. Statistical analysis was performed on a per-flap basis. RESULTS: A total of 157 unilateral and 42 bilateral deep inferior epigastric perforator flaps were identified. The rate of intra-operative complications was 12.1% for unilateral versus. 4.8% for bilateral flaps (P=0.26). Total post-operative complications rates were 30.6% for unilateral versus 54.7% for bilateral flaps (P=0.003). Surgical re-exploration was performed in 12.7% of unilateral and 11.9% of bilateral cases (P=0.88). The rate of total flap loss was similar between types of reconstruction, occurring in 2.5% of unilateral vs. 2.4% of bilateral flaps (P=1). CONCLUSION: This study demonstrates the rate of complications per flap is significantly higher in bilateral versus unilateral deep inferior epigastric perforator flap breast reconstruction. Bilateral DIEP breast reconstruction should be decided on a case-by-case basis. LEVEL OF EVIDENCE: Prognostic/Risk Study, Level II.

[Bilateral breast reconstruction by DIEP flap in two stages: Technical note]. / Reconstruction mammaire bilaterale par lambeau de DIEP en deux temps : note technique.

With the rise of risk prevention surgery, more and more bilateral mastectomies are performed. These present a challenge when patients desire autologous reconstruction. Some surgeons perform reconstructions using a double DIEP flap, but this technique, which requires rapid operation and extensive experience, can sometimes be difficult to implement. Other factors may also favor a two-stage reconstruction, one breast after the other. We present here our technique to harvest two hemi-DIEP during two distinct operating times, by modifying the design of the first flap and by performing a prior autonomization of the second.

Differences between novel hybrid mode flaps and traditional perforator flaps at the level of metabolites using LC-MS.

The multi-territory perforator flaps are widely used in plastic surgery. However, partial necrosis flap in the potential territory remains a challenge to plastic surgeons. We raised a novel "hybrid nourished mode" (HNM) flap based on the multi-territory deep inferior epigastric perforator (DIEP) flap to improve flap survival. Thirty-two rabbits were randomly divided into DIEP and HNM groups. Untargeted metabolic mechanisms between the DIEP and HNM groups were performed using LC-MS under the filter criteria of fold change >20.0 times or <0.05, and variable importance in projection (VIP) value was set at ≥1, P < 0.05. Between the two groups, flap survival, perfusion, microvasculature, histopathology, and immunohistochemistry of CD31 were assessed on post-operative day 7. We screened 16 different metabolites that mainly participated in biosynthesis of secondary metabolites, aminoacyl transfer RNA biosynthesis, phenylalanine metabolism, arginine and proline metabolism, among others. The results of the HNM flaps were higher than those of the DIEP flaps (P < 0.05) in the aspects of flap survival, flap perfusion, and microvasculature. Compared with the DIEP flaps, HNM has a stronger advantage in tissue metabolism. This study provided us with a better understanding and strong evidence in terms of metabolites on how HNM achieves the survival of large multi-territory perforator flaps.

Neurotization Does not Prolong Operative Time in Free Flap Breast Reconstruction.

BACKGROUND: Neurotization during the breast reconstruction process can improve patient quality-of-life and satisfaction with reconstructive outcomes. One concern with neurotization is increased total operative time due to the need for additional dissection and nerve coaptation. The purpose of this study was to compare total operative time between neurotized and non-neurotized abdominal-based, free flap breast reconstruction. METHODS: A retrospective review was conducted of consecutive patients who underwent unilateral, abdominal-based, free flap breast reconstruction between 2016 and 2018 at a single tertiary care center. Data were collected on patient demographics, surgical techniques, and length of surgery. Data analysis was performed using chi-square test, independent t-test, and multivariate linear regression analysis. A p-value ≤0.05 was considered statistically significant. RESULTS: Seventy-three patients were included in this study. Twenty-three patients (31.50%) underwent flap neurotization (N group) and 50 (68.49%) underwent standard breast reconstruction without neurotization (NO group). The groups were similar in age, BMI, smoking status, and ASA class. No difference was found between the two groups in timing of reconstruction (p = 0.388). Average operative times were 467.73 ± 145.52 minutes and 455.28 ± 111.19 minutes for the N and NO groups, respectively, with no significant difference between the two groups (two-tailed p-value = 0.72). CONCLUSION: Seamless integration of neurotization in abdominal-based, free flap breast reconstruction is possible without significant prolongation of total operative time. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Impact on Patient's Appearance Perception of Autologous and Implant Based Breast Reconstruction Following Mastectomy Using BREAST-Q.

INTRODUCTION: The purpose of this study is to determine if there is a better quality of life with one of the two techniques and if the results are in line with those already present in the literature. The hypothesis from which we started is to demonstrate that cancer patients who undergo a deep inferior epigastric perforator flap (DIEP) breast reconstruction surgery are more satisfied and have a higher level of quality of life compared to those subjected to an intervention of reconstruction with prosthesis. MATERIALS AND METHODS: All patients undergoing reconstruction from January 2010 to July 2018 were eligible for inclusion. This is a retrospective cohort study carried out using the patients of two plastic surgery departments who have undergone monolateral or bilateral implant-based or DIEP flap breast reconstruction. We administered BREAST-Q questionnaire electronically almost 2 year after surgery. Patients were divided into two groups: implant-based and autologous breast reconstruction with DIEP flaps. Baseline demographics and patient characteristics were analyzed using a Students t-test (continuous variables) or Chi-square/Fisher's exact test (categorical variables). Mean standard deviation BREAST-Q scores were reported for the overall cohort and by modality for the postoperative period. The linear regression model was applied to all BREAST-Q score with all predictor factors. RESULTS: Of the 1125 patients involved, only 325 met the inclusion criteria and were enrolled in this study; specifically, 133 (41%) DIEP and 192 (59%) prosthetic reconstructions. We summarized the results of the principal scales of BREAST-Q module: satisfaction with breast, psychosocial well-being, satisfaction with outcome, and sexual well-being in which the autologous group was always more satisfied. We reported results of all linear regression models with higher values for the DIEP group independently from predictors. CONCLUSION: This is the first study performed on the Italian population that compares autologous surgical techniques with the implantation of breast implants. In this population, DIEP is considered the technique that leads to the highest satisfaction in all BREAST-Q scores. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Predictive Factors of Satisfaction Following Breast Reconstruction: Do they Influence Patients?

INTRODUCTION: This study aims to analyze whether there is any patient- or treatment-related factor that can influence patients' body perception after mastectomy and autologous or implant-based breast reconstruction. MATERIALS AND METHODS: This retrospective cohort study included patients who underwent immediate implant-based or DIEP flap breast reconstruction. Predictive factors analyzed included chemotherapy, radiotherapy, hormone therapy, body mass index, age, type of mastectomy, and follow-up length. The BREAST-Q was administered postoperatively almost 2 years from the last surgical procedure. Mean BREAST-Q scores were reported for the overall cohort and by modality for the postoperative period. A linear regression model was applied to all BREAST-Q scores with all predictor factors. RESULTS: In total, 325 patients were enrolled in this study (133 DIEP flap and 192 implant-based reconstructions). The DIEP flap reconstruction group with a previous nipple sparing mastectomy showed the highest scores. Patients with a longer follow-up were less satisfied than the ones with a shorter follow-up, which could be considered as an assessment of the outcome. No significant difference was reported between patients who underwent radiotherapy, chemotherapy or hormone therapy and those who did not. Furthermore, age and BMI had no influence on patient satisfaction. CONCLUSION: This study is the first that groups a large number of patients and analyzes predictive factors of long-term satisfaction of patients undergoing breast reconstruction. This can be regarded as a pilot study to raise the awareness of everyone's clinical practice to predict the attitude that patients have after surgery and to prepare them in the best possible way. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com .

[A pedicled deep inferior epigastric flap to cover a hip arthroplasty infection]. / Couverture d'une prothèse de hanche infectée par un lambeau perforant épigastique inférieur profond pédiculé.

The deep inferior epigastric perforator (DIEP) flap is a reliable flap mostly used in skin resurfacing after signifiant resection for sarcoma or correction contour deformities. This case is about a pedicled DIEP flap covering the trochanteric region after a total hip arthroplasty infection. A 62years old woman with a BMI at 42kg/m2 presents an infected total hip arthroplasty with a cutaneous defect. The hip prosthesis is changed and covered with a pedicled DIEP flap. This original case reports the used of pedicled DIEP flap in hip coverage. This local fasciocutaneous flap covered the hip osteoarticular infection. The limb is salved and the patient can walked again. The success of this surgery is the collaboration between infectious disease specialist, orthopedic surgeon and plastic surgeon.

Utilizing the Retrograde Flow of Internal Mammary Vessels as a Donor Pedicle.

Introduction The aim of this study is to assess the results of retrograde flow of internal mammary artery and vein (IMA/V) as a donor vessel for free flap microvascular anastomosis (MVA). This need arises with bipedicle deep inferior epigastric perforator (DIEP) flaps, when all four zones with extra fat need to be harvested for unilateral breast reconstruction coupled with poor midline crossover of circulation naturally or because of midline scar. Large anterolateral thigh flaps for chest wall cover, with multiple perforators from separate pedicles, also need supercharging. This needs an additional source of donor vessels, antegrade IMA/V being the first one. Materials and Methods Retrospective study of microvascular breast reconstruction using retrograde internal mammary donor vessels. Results Out of 35 cases, 20 cases had distal IMA/V, with retrograde flow, as donor vessel for second set of arterial and venous anastomosis. In two cases, retrograde IMA/V was used for the solitary set of MVA. In remaining 13 cases, either retrograde IMA or V was utilized either as a principal or accessory donor. No flap was lost. Venous and arterial insufficiency happened in one case each, both were salvaged. Two cases developed partial necrosis, needing debridement and suturing. One case developed marginal necrosis. Only one case developed fat necrosis with superadded infection on follow-up. Conclusion Distal end of IMA and IMV on retrograde flow is safe for MVA as an additional or sole pedicle. It is convenient to use being in the same field. It enables preservation of other including thoracodorsal pedicle and latissimus dorsi flap for use in case of a complication or recurrence.

The difference in local, regional and distant breast cancer recurrence between the immediate and delayed DIEP flap procedure; a retrospective cohort study.

PURPOSE: It has been hypothesized that autologous breast reconstruction can cause reactivation of dormant micro metastases by its extensive tissue trauma, influencing the risk of breast cancer recurrence. However, about the specific effect of timing on breast cancer recurrence in the deep inferior epigastric perforator (DIEP) flap reconstruction is not much known. In this study the rate of local, regional and distant recurrence between patients undergoing an immediate and delayed autologous DIEP flap breast reconstruction were evaluated. METHODS: In this retrospective cohort study, breast cancer patients undergoing a DIEP flap breast reconstruction between 2010 and 2018 in three hospitals in the Netherlands were evaluated. Cox proportional hazards regression analyses were performed to assess the impact of different factors on breast cancer recurrence. The primary endpoint was local breast cancer recurrence. Secondary endpoints were regional and distant recurrence. RESULTS: A total of 919 DIEP-flap reconstructions were done in 862 women of which 347 were immediate- and 572 were delayed DIEP flap reconstructions. After a median follow-up of 46 months and 86 months respectively (p < 0.001), local breast cancer recurrence occurred in 1.5% and in 1.7% of the patients resulting in an adjusted hazard ratio of 2.890 (p = 0.001, 95% CI 1.536, 5437). CONCLUSION: This study suggests an increased risk for breast cancer recurrence in women receiving a delayed DIEP flap reconstruction as compared to women receiving an immediate DIEP flap reconstruction. However, these data should be interpreted carefully as a result of selection bias.

Predicting the Feasibility of Utilizing SIEA Flap for Breast Reconstruction with Preoperative BMI and Computed Tomography Angiography (CTA) Data.

BACKGROUND: Diameters greater than 1.5 mm are considered one of the generally accepted criteria for utilizing superficial epigastric artery (SIEA) flaps for breast reconstruction. However, this standard fails to consider individual differences among patients or deep inferior epigastric perforator (DIEP) perfusion of the same angiosome as the SIEA. This study combined the SIEA system with the DIEP system and explored the relationship between the two systems and body mass index (BMI) to theoretically provide a reference for flap choice in the preoperative surgical plan. METHODS: This study analysed preoperative computed tomography angiography (CTA) data from patients who received systematically postoperative treatment for unilateral breast cancer and were scheduled for breast reconstruction from 2013 to 2018 in our centre. All patients included had no past medical history that might have influenced the diameter of the SIEA, and their CTA data showed the presence of SIEA. RESULTS: Twenty-five females with a mean BMI of 23.6 ± 3.3 kg/m2 were included. A total of 30 hemi-abdomens identified with the SIEA were assessed. The measured mean diameter of the SIEA was 1.63 ± 0.55 mm, showing a highly linear correlation with BMI (r = 0.73, p < 0.001), while the maximum diameter of the deep inferior epigastric perforator (DIEPmax) and the number of dominant perforators originating from the deep inferior epigastric artery (DIEA) were not related to BMI. It was analysed from the equation between the calibre of the SIEA and BMI that when the BMI was greater than or equal to 24 kg/m2, the minimum diameter of the SIEA was at least 1.5 mm; when the BMI was 25 kg/m2, the diameter of the SIEA was, at most, 2.0 mm. Based on the linear correlation described above, we proposed that if the diameter of the SIEA was greater than or equal to 2.0 mm, a BMI ≥ 25 kg/m2 could be fully guaranteed. In terms of the advantageous single pedicle for reconstruction, the ratio of the SIEA diameter to DIEPmax (SIEA/DIEPmax) showed a significant linear correlation with BMI (r = 0.82, p < 0.001), and when the BMI was greater than or equal to 25 kg/m2, the lower limit of its predicted value was above 1.0; in other words, the SIEA diameter was advantageous compared with DIEPmax for the use of a single pedicle. In terms of perfusion, the SIEA system was positively correlated with BMI (p < 0.001), while the DIEP system was not. The difference in perfusion level between the SIEA and DIEP systems showed a positive correlation with BMI (p = 0.001), while the sum of the two systems only tended to be correlated, without statistical significance (p = 0.06). CONCLUSIONS: For patients with a BMI ≥ 25 kg/m2 or an SIEA diameter ≥ 2.0 mm, application of an SIEA flap is theoretically a preferable choice in preoperative surgical planning for breast reconstruction. And the patients should meet two conditions: the first one is the absence of past medical history that might potentially influence the diameter of the SIEA; the second is the presence of the SIEA, which has already been shown by the preoperative imaging data. Through perfusion-related studies, we propose that the SIEA is likely a compensatory vessel that is inclined to present in people with larger BMIs. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Bilateral DIEP flap breast reconstruction with simultaneous unilateral nipple-sparing mastectomy - case report.

With the steady increase in the incidence of breast cancer in women, treatment that includes not only tumor removal but also breast reconstruction is becoming a more relevant issue for oncologic and plastic surgeons. Mastectomy recently evolved as a form of primary prevention of hereditary breast cancer, commonly performed in combination with simultaneous reconstruction. A case of 44-year-old woman who underwent right mastectomy with adjuvant radiotherapy is presented. Due to the patient's positivity for BRCA1 mutation and her wishes, a risk-reducing mastectomy with nipple-areola complex preservation and bilateral deep inferior epigastric artery perforator flap reconstruction were performed in one-stage. In selected cases this method appears to be the best possible procedure for simultaneous preventative and reconstructive management in patients with genetically determined breast cancer who have undergone mastectomy with radiotherapy.