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.

Efficacy of superficial inferior epigastric vein superdrainage in free TRAM and DIEP flap: An indocyanine green angiography study of 68 cases.

BACKGROUND: This study aimed to evaluate the clinical efficacy of venous augmentation using superficial inferior epigastric vein (SIEV) in free transverse rectus abdominis musculocutaneous (TRAM) and deep inferior epigastric artery perforator (DIEP) flap and investigate the factors that hinder the venous superdrainage. METHODS: A retrospective review of 62 free muscle-sparing (MS)-TRAM and 6 DIEP unilateral breast reconstructions from September 2017 to July 2022. Intraoperative indocyanine green angiography was performed on the harvested flap, with the SIEV contralateral to the pedicle side clamped and unclamped for 20 min. The relative ratio of hypoperfused area to the total flap area was calculated and compared quantitatively. The preoperative computed tomography (CT) angiography was reviewed to obtain information on the SIEV diameter and number of midline-crossing medial branches. RESULTS: The participants were categorized into three groups: 42 patients in Group 1 (>3% decrease in hypoperfused area), 20 patients in Group 2 (change in hypoperfused area ranging from -3% to 3%), and six patients in Group 3 (>3% increase in hypoperfused area). The mean number of midline-crossing branches (p = 0.002) and mean difference in the diameter of bilateral SIEVs (p = 0.039) were significantly greater in Group 1 than in the other groups. CONCLUSIONS: Thirty-eight percent (26/68 cases) resulted in sustained or aggravated perfusion after SIEV superdrainage. Superdrainage using the contralateral SIEV in free MS-TRAM/DIEP flap is recommended when there are more than two midline-crossing medial branches of SIEV and when the caliber of SIEV is relatively greater compared with the pedicle side.

Modern Approaches to Abdominal-Based Breast Reconstruction.

Modern approaches to abdominal-based breast reconstruction have evolved since the introduction of the transverse musculocutaneous flap by Dr Carl Hartrampf in the 1980s. The natural evolution of this flap is the deep inferior epigastric perforator (DIEP) flap, as well as the superficial inferior epigastric artery flap. As breast reconstruction has advanced, so too has the utility and nuances of abdominal-based flaps, including the deep circumflex iliac artery flap, extended flaps, stacked flaps; neurotization; and perforator exchange techniques. Even the delay phenomenon has been successfully applied to DIEP and SIEA flaps to augment flap perfusion.

Morbidity of the Donor Site and Complication Rates of Breast Reconstruction with Autologous Abdominal Flaps: A Systematic Review and Meta-Analysis.

Background: Numerous studies have evaluated the use of autologous abdominal tissue for breast reconstruction; nevertheless, complications and donor site morbidity rates vary significantly. The study aims to compare the literature regarding morbidity of the donor site and complication rates of breast reconstruction with autologous abdominal flaps. Methods: The databases of MEDLINE, EBSCO, Scopus, Wiley Library, and Web of Sciences were searched for studies that compared different flaps in terms of complications and donor site morbidity. The procedures studied included pedicled transverse rectus abdominis myocutaneous flap (pTRAM), free TRAM (fTRAM), deep inferior epigastric perforator (DIEP), and superficial inferior epigastric artery perforator (SIEA) flaps. A total of 34 studies were included. Of these, 28 were retrospective studies and 9 were prospective cohort studies. Results: When compared to DIEP, fTRAM flaps were found to have a decreased incidence of flap fat necrosis, hematoma, and total thrombotic events, yet a higher risk of donor site hernia/bulging. pTRAM flaps were also associated with an increased risk of hernia/bulging at the donor site, as well as wound infection, yet flap hematoma was less common. On the other hand, SIEA flaps showed the lowest risk of donor site hernia/bulging while still having a high risk of wound infection. Conclusion: fTRAM procedures comparatively had the least complications. However, regarding flap choice, patients would benefit most from a case-by-case analysis, taking into consideration individual risk factors and preferences.

Comparison of 30-degree and 0-degree laparoscopes in the visualisation of the inferior epigastric vessel, rectus abdominis muscle and bladder dome in gynaecologic laparoscopy.

Clear visualisation of the inferior epigastric vessel and bladder dome is important to avoid ancillary port injury. In this prospective cohort study, 52 videos of gynaecologic laparoscopies performed at Songklanagarind Hospital were scored by three expert and three non-expert surgeons in terms of visualisation quality and confidence level in identifying the inferior epigastric vessel, rectus abdominis muscle and bladder dome using 0-degree and 30-degree laparoscopes. No significant difference was reported between the laparoscopes regarding both visualisation quality and confidence level in identifying these three landmarks. When using the 30-degree laparoscope, expert surgeons reported significantly higher visual rating scale scores for both visualisation quality and confidence level than did non-expert surgeons (7.6 (5.3-8.6) vs. 6.5 (4.4-8.3); p=.04 and 7.3 (5.7-8.6) vs. 6.2 (5.2-7.5); p=.02). In conclusion, the two laparoscope angles were similar in terms of both visualisation quality and confidence level in visualising the inferior epigastric vessel and bladder dome.Impact StatementWhat is already known on this subject? Most laparoscopic complications associated with vascular and bladder injuries occur during the process of abdominal penetration. The 30-degree laparoscope tends to be superior to the 0-degree laparoscope in terms of visualisation in the lateral axis. A previous study reported the benefits of using the 30-degree laparoscope in urologic surgery. Data related to the degree of the laparoscope suitable for avoiding abdominal wall injuries are lacking.What do the results of this study add? We demonstrated that both 0- and 30-degree laparoscopes were similar in terms of visualisation and confidence level for the identification of the inferior epigastric vessel and bladder dome. Using the 30-degree laparoscope, expert surgeons reported higher scores for the visualisation of the inferior epigastric vessel than did non-expert surgeons.What are the implications of these findings for clinical practice and/or further research? Before ancillary port penetration, we recommend using either a 30-degree or 0-degree laparoscope to visualise the inferior epigastric vessel and bladder dome. For non-expert surgeons, a learning curve is required to improve the visualisation quality and confidence level for identifying these landmarks, especially using the 30-degree laparoscope.

The third dimension in perforator mapping-Comparison of Cinematic Rendering and maximum intensity projection in abdominal-based autologous breast reconstruction.

BACKGROUND: Cinematic Rendering (CR) is a recently introduced post-processing three-dimensional (3D) visualization imaging tool. The aim of this study was to assess its clinical value in the preoperative planning of deep inferior epigastric artery perforator (DIEP) or muscle-sparing transverse rectus abdominis myocutaneous (MS-TRAM) flaps, and to compare it with maximum intensity projection (MIP) images. The study presents the first application of CR for perforator mapping prior to autologous breast reconstruction. METHODS: Two senior surgeons independently analyzed CR and MIP images based on computed tomography angiography (CTA) datasets of 20 patients in terms of vascular pedicle characteristics, the possibility to harvest a DIEP or MS-TRAM flap, and the side of the flap harvest. We calculated inter- and intra-observer agreement in order to examine the accordance of both image techniques. RESULTS: We observed a good inter- and intra-observer agreement concerning the type of flap and the side of the flap harvest. However, the agreement on the pedicle characteristics varies depending on the considered variable. Both investigators identified a significantly higher number of perforators with MIP compared with CR (observer 1, p<0.0001 and observer 2, p<0.0385). CONCLUSION: The current study serves as an explorative study, showing first experiences with CR in abdominal-based autologous breast reconstruction. In addition to MIP images, CR might improve the surgeon's understanding of the individual's anatomy. Future studies are required to compare CR with other 3D visualization tools and its possible effects on operative parameters.

Anatomical study and clinical importance of the inferior epigastric artery / Estudio anatómico e importancia clínica de la arteria epigástrica inferior

SUMMARY: The inferior epigastric artery (IEA) is a major blood vessel that supplies the anterior abdominal wall. The aim of the current study was to provide clinicians, surgeons, and obstetricians with sufficient anatomical data on the inferior epigastric artery, such as its origin and branching pattern. The study included 20 embalmed cadavers, these cadavers were dissected, and the inferior epigastric artery and vena comitans/venae comitantes were identified and traced downwards to the external iliac vessels. The origins, caliber, course and pedicle length of both the artery and the vein(s) were studied. The inferior epigastric artery arose independently from the distal external iliac artery deep to the inguinal ligament in 19 (95 %) cadavers. The artery entered the rectus abdominis muscle at its middle third in 13 (65 %) cases and at its lower third in the remaining specimens. In this study, we found that the artery divided into two branches in 18 (90 %) of the cases; in the remaining two cases, it continued as one trunk. The average pedicle length was 7.2 cm. The mean caliber of the IEA was 3.7 mm. In 18 (90 %) dissections, the venous drainage consisted of a pair of venae comitantes that united to form a common vessel at their draining point on the external iliac vein. The average diameter was 3.9 mm. The current study focuses on the anatomical features of the inferior epigastric artery to increase the success rate of abdominal and pelvic operations in clinical practice.

RESUMEN: La arteria epigástrica inferior (AEI) es un vaso sanguíneo principal que irriga la pared abdominal anterior. El objetivo del presente estudio fue proporcionar a los médicos, cirujanos y obstetras suficientes datos anatómicos sobre la arteria epigástrica inferior, como su origen y patrón de ramificación. El estudio incluyó 20 cadáveres embalsamados, los que se disecaron y se identificó la arteria epigástrica inferior y la vena concomitante y se siguieron hasta los vasos ilíacos externos. Se estudiaron los orígenes, calibre, trayecto y longitud del pedículo tanto de la arteria como de la (s) vena (s). La arteria epigástrica inferior surgió independientemente de la arteria ilíaca externa profunda al ligamento inguinal en 19 (95 %) cadáveres. La arteria ingresó al músculo recto del abdomen en su tercio medio en 13 (65 %) casos y en su tercio inferior en las muestras restantes. En este estudio, encontramos que la arteria se dividió en dos ramas en 18 (90 %) de los casos; en los dos casos restantes, continuó como un tronco. La longitud media del pedículo fue de 7,2 cm. El calibre medio del AEI fue de 3,7 mm. En 18 (90 %) disecciones, el drenaje venoso consistió en un par de venas concomitantes las que formaron un vaso común en su punto de drenaje en la vena ilíaca externa. El diámetro medio fue de 3,9 mm. El estudio actual se centra en las características anatómicas de la arteria epigástrica inferior con el propósito de mejorar la tasa de éxito de las cirugías abdominales y pélvicas en la práctica clínica.

Clinical course of venous thromboembolism following abdominally based microsurgical breast reconstruction: A case series.

BACKGROUND: Venous thromboembolism (VTE) is a potentially devastating complication following abdominally based microsurgical breast reconstruction, with a reported incidence of 0.08-4%. The authors aim to describe disease presentation and clinical course following VTE diagnosis in patients within their practice. METHODS: A retrospective chart review identified patients who underwent microsurgical breast reconstruction from January 2007 through December 2018. Patients with VTE diagnosed within 90 days of surgery were included. Demographics, co-morbidities, signs and symptoms, and characteristics of oncologic, surgical, and post-operative care were analyzed. RESULTS: Seven hundred one patients underwent microsurgical breast reconstruction. Eleven patients with pulmonary embolism (PE) and four with deep vein thrombosis (DVT) were identified, resulting in VTE incidence of 2.1% (0.57% DVT, 1.6% PE). Patients were on average 51 years old and had an average body mass index (BMI) of 31.7 kg/m2. Two had a history of VTE, and none had a known hypercoagulable disorder. Using the 2005 Caprini model, all were high risk and seven were highest risk. Among those with PE, the most common symptom was shortness of breath, and the most common signs were desaturation or supplemental oxygen requirements. VTE was diagnosed on average 14.2 days post-operatively (range 2-52 days). CONCLUSION: VTE is an infrequent complication following abdominally based microsurgical breast reconstruction. We recommend a high index of suspicion in women reporting shortness of breath or having desaturation, especially in those with high BMI, high Caprini scores, post-operative complications, or early return to the operating room.

Novel Design of the Chimeric Deep Inferior Epigastric Artery Perforator Flap that Provides for Three-Dimensional Reconstruction of Composite Tissue Defects of the Heel in Children.

OBJECTIVE: The aim of the present study was to report a novel design of the chimeric deep inferior epigastric artery perforator flap (DIEP) to achieve dead space filling, Achilles tendon bridging, and skin resurfacing simultaneously with minimal donor-site morbidity. METHODS: From September 2012 to May 2016, a retrospective study was carried out on six pediatric patients with composite soft tissue defects of the heel that were repaired with the chimeric DIEP flap. The chimeric flap design included a flap of the anterior sheath of the rectus, a block of rectus muscle, and a large skin paddle. All the parts were supplied by a common artery. After harvesting the flap, all element parts were inserted at the corresponding sites in a tension-free manner. With one set of vessel anastomoses at the recipient site, accurate repair with tendon reconstruction, dead space elimination, and wound covering were accomplished. The donor site incisions were closed initially. Data on patient age, medical history, injury severity, defect size, flap dimensions, recipient vessels, donor site closure, complications, and follow-up were collected and reviewed. RESULTS: Five of the six chimeric DIEP flaps survived without complications. The remaining one case experienced partial necrosis of the skin paddle caused by venous congestion, which healed after routine dressing changes. Primary donor site closure was accomplished in all cases. The mean follow-up was 18.6 months (range, 10-36 months). Five patients had satisfactory aesthetic and functional outcomes; one patient needed a secondary debulking procedure. Compared to the unaffected side, the affected side showed no obvious difference for ankle movement, tiptoe function, and patient gait during the follow-up period. Good ankle function was observed in all patients. There was no donor site breakdown, with only a slightly noticeable linear scar. CONCLUSION: The chimeric DIEP flap reduced the operative time, solved the problem of deficiency of recipient vessels, and attained satisfactory functional and aesthetic outcomes with low donor site morbidity. Therefore, it is a promising option for three-dimensional reconstruction of composite defects with dead space and Achilles tendon defects as well as skin loss in children.

A short-term comparison of expander prosthesis and DIEP flap in breast reconstructions: A prospective randomized study.

BACKGROUND: There is yet no clear consensus on which method is preferable in secondary breast reconstructions, prosthesis, or autologous tissue. METHODS: In this first prospective randomized study, 29 women underwent reconstruction with expander prosthesis (EP) and 44 with deep inferior epigastric perforator (DIEP) flap. Inclusion started in 2012 and ended in 2018. Demographic data, complications, surgery time, hospital days, and consulting visits were recorded. Patient satisfaction was evaluated pre- and postoperatively using the BREAST-Q questionnaire. Health care costs were calculated based on rates from the financial year 2018. Here, we report the results related to the surgery and the first 30 postoperative days. RESULTS: The two groups were comparable regarding demographics and clinical characteristics. Satisfaction with breasts, measured with BREAST-Q, was significantly higher in patients who had undergone reconstruction with DIEP flap compared with EP. Within 30 days after breast reconstruction, significantly fewer women (n = 2) in the EP group suffered complications compared to the DIEP flap group (n = 16; p < 0.01). The health care cost was also significantly higher in the DIEP flap group relative to the EP group (p < 0.01). DISCUSSION: This patient cohort will be studied systematically over time, and results concerning the need for complementary surgery, costs, esthetics, and the patient-reported outcome (PRO) will be reported in future work. In this short-term report, EP seems to be preferable in regard to cost and complications, and DIEP flap is to choose from the patient's perspective.

A case of spontaneous rectus sheath hematoma induced by lateral semi-prone positional changes during extracorporeal membrane oxygenation.

Spontaneous abdominal wall hematomas are relatively rare and mainly attributed to anticoagulation and severe cough. Despite the high incidence of anticoagulation-related bleeding complications, there are no reports of spontaneous abdominal wall hematomas during extracorporeal membrane oxygenation (ECMO). We report a case of a spontaneous rectus sheath hematoma caused by alternation of the lateral semi-prone position during ECMO in a 76-year-old female patient with severe acute respiratory distress syndrome. Unfractionated heparin 12,000-14,000 units/day was administered for anticoagulation during ECMO. From Day 6 of ECMO, the patient who was under deep sedation was alternately placed in the left and right lateral semi-prone positions every 4 h, for approximately 20 h per day. On Day 12 of ECMO, the patient developed hypotension with anemia and a palpable mass in the right lower abdomen. Abdominal ultrasonographic imaging revealed a huge echo-free space centered in the right lower abdomen. Emergency contrast-enhanced computed tomography (CT) scanning showed extravasation from the superior and inferior epigastric arteries as well as a rectus sheath hematoma. Despite no apparent contrast leakage, an inferior epigastric artery embolization was undertaken because the patient was on ECMO. On Day 13 after ECMO initiation, ECMO and anticoagulation were discontinued. On CT scanning a week later, the hematoma had reduced. In conclusion, spontaneous abdominal wall hematoma is a rare and important complication that might occur during ECMO. Thus, careful physical examination should be routinely conducted when the patient is semi-prone during ECMO.

Characteristics and outcomes of primary interposition vascular grafts in free flap breast reconstruction.

INTRODUCTION: There is paucity of data on primary interposition vascular grafts (IVG) use in microsurgery. Our study examines the characteristics, indications and outcomes of IVG in free flap breast reconstruction. METHODS: All cases of breast reconstruction with free flaps between January 2013 and June 2018 were examined and cases with primary IVG were included. Data were collected on patient, flap and graft characteristics, indications and outcomes. RESULTS: A total of 76 IVG, specifically 65 vein grafts and 11 arterial grafts, were used for 49 (of 1547) flaps in 48 (of 1346) cases. Of these, 52 grafts were primarily used to lengthen the pedicle and aid flap inset and 24 grafts to augment venous flow; 49 grafts were harvested from the flap harvest site, 7 from the anastomosis recipient site and 20 from a separate site. Of the total, 16.7% (8/49 flaps) required salvage procedures - seven cases for venous congestion and one for ischaemic compromise - in comparison to 4.3% in cases without IVG (65/1498) (p<0.0001). Out of 49 IVG flaps, three (6.1%) failed in comparison to 1.7% (26/1498), where IVG flaps were not used (p<0.05). Two were transverse upper gracilis flaps with vessel calibre mismatch, and one lumbar artery perforator (LAP) flap with past infected implant and failed deep inferior epigastric artery (DIEP). CONCLUSION: We present the largest number of primary vascular grafts for free flap breast reconstruction in the literature. Primary IVG were used for at-risk flaps and had a success rate of 93.9%. This shows that IVG are a viable option to prevent venous congestion and lengthen the pedicle to aid inset and shaping; they are associated with higher complication rates bearing in mind the high-risk profile of the flaps these are used for.

An anatomic study of deep inferior epigastric artery diameters at the origin from external iliac and at the lateral border of rectus abdominis muscle by computed tomographic angiography from autologous breast reconstruction patients.

BACKGROUND: Autologous breast reconstruction by means of microsurgical abdominal flaps is an very well described technique. The flap harvest dissection under inguinal ligament would cause the risk of parietal weakening in this zone and postoperative bulging. The goal of our study is to investigate whether the deep inferior epigastric artery diameter remains constant from its exit of the external iliac artery to its entrance in the rectus muscle sheath. PATIENTS AND METHOD: One hundred arteries were studied on fifty preoperative computed tomographic angiographies made before a DIEAP flap for breast reconstruction. We measured the caliber of the left and right deep inferior epigastric arteries at these two landmarks. The length of this artery between these was also calculated. This data were collected with specific angiography reconstruction. RESULTS: At the caudal landmark, the mean DIEA diameter was 2.1±0.27mm on the left side and 2.1±0.31mm on the right side. At the cephalic landmark, the mean DIEA diameter was 2.0±0.28mm on the left and 2.0±0.27mm on the right side (P=0.00035 at left side; P=0.0089 at right side). The mean pedicle length between the two landmarks was 22.3±2.85mm on the left side and 22.2±2.98mm on the right side. CONCLUSION: This computed tomographic angiography study showed that the diameter of DIEA is equivalent at its origin and at the lateral border of muscle. Flap harvest without dissection under inguinal ligament provides sufficient pedicle length and caliber to allow for comfortable and reliable sutures.

Arterial Anatomy of the Anterior Abdominal Wall: Evidence-Based Safe Sites for Instrumentation Based on Radiological Analysis of 100 Patients.

Multiple medical interventions require percutaneous instrumentation of the anterior abdominal wall, all of which carry a potential for vascular trauma. We assessed the presence, position, and size of the anterior abdominal wall superior and inferior (deep) epigastric arteries to determine the safest site with respect to vascular anatomy of the rectus sheath. In a review of 100 arterial phase, contrast-enhanced abdominal computed tomography scans, anterior abdominal wall arteries were assessed bilaterally at three axial planes: transpyloric, umbilicus, and anterior superior iliac spine (ASIS). The mean age of patients was 69.2 years (SD ± 15), with 62 male and 38 female. An artery was visible least frequently at the transpyloric plane (5%), compared with the umbilicus (72-79%) and ASIS (93-96%), on the left (χ2 (4) = 207.272; P < 0.001) and right (χ2 (4) = 198.553; P < 0.001), with a moderate strength association (Cramer's V = 0.588 (left) and 0.575 (right)). The arteries were most commonly observed within the rectus abdominis muscle at the level of the umbilicus and ASIS on both sides (62-68%). The inferior epigastric artery was observed to be larger in diameter, start more laterally, and move medially as it travelled superiorly. These data suggest that the safest site to instrument the rectus sheath, with respect to vascular anatomy, is at the transpyloric plane. This information on anatomical variation of the anterior abdominal wall vasculature may be of particular interest to anesthetists performing rectus sheath block and surgeons during laparoscopic port insertion. Clin. Anat. 33:350-354, 2020. © 2019 Wiley Periodicals, Inc.

Effects of vasopressors on circulation in the porcine abdominal island flap model.

BACKGROUND: During reconstructive surgical procedures, systemic vasopressors are frequently used to maintain normal blood pressure. However, questions have arisen regarding the pharmacologic effects of vasopressors on flap circulation. Many plastic surgeons have expressed concern about the possibility of impaired flap circulation caused by the vasoconstrictive effect of the drugs. However, the opposing argument exists that the increase in mean arterial pressure from vasoactive agents may improve flap perfusion. The purpose of this study was to evaluate the effect of commonly used vasopressors on flap circulation. METHODS: The vertical rectus abdominis myocutaneous (VRAM) island flap was raised in five female pigs (38.2∼40.7 kg). Hemodynamic parameters were measured continuously by a carotid arterial catheter. A bi-directional transonic vascular doppler flow probe and Laser Doppler perfusion monitor (LDPM) unit were applied to record the continuous change in pedicle artery flow and microvascular perfusion following intravenous administration of dopamine (3, 5, 10µg/kg/minute), dobutamine (1.25, 2.5, 5µg/kg/minute), and norepinephrine (0.05, 0.1, 0.2µg/kg/minute). RESULTS: Both microvascular perfusion and pedicle flow were generally proportional to the mean arterial pressure, and all three vasopressors improved flap perfusion and pedicle flow without deleterious effects. Norepinephrine showed the highest microvascular perfusion and dobutamine showed the highest pedicle flow rate. The mean blood pressure was the only statistically significant factor to affect both microvascular perfusion and pedicle flow (p < 0.0001). CONCLUSION: Our results strongly suggest that the foremost three vasopressors can be used for flap surgery without deterioration, and that the maintenance of adequate systemic blood pressure is crucial for good flap circulation.

Abdominal functional electrical stimulation to assist ventilator weaning in critical illness: a double-blinded, randomised, sham-controlled pilot study.

BACKGROUND: For every day a person is dependent on mechanical ventilation, respiratory and cardiac complications increase, quality of life decreases and costs increase by > $USD 1500. Interventions that improve respiratory muscle function during mechanical ventilation can reduce ventilation duration. The aim of this pilot study was to assess the feasibility of employing an abdominal functional electrical stimulation (abdominal FES) training program with critically ill mechanically ventilated patients. We also investigated the effect of abdominal FES on respiratory muscle atrophy, mechanical ventilation duration and intensive care unit (ICU) length of stay. METHODS: Twenty critically ill mechanically ventilated participants were recruited over a 6-month period from one metropolitan teaching hospital. They were randomly assigned to receive active or sham (control) abdominal FES for 30 min, twice per day, 5 days per week, until ICU discharge. Feasibility was assessed through participant compliance to stimulation sessions. Abdominal and diaphragm muscle thickness were measured using ultrasound 3 times in the first week, and weekly thereafter by a blinded assessor. Respiratory function was recorded when the participant could first breathe independently and at ICU discharge, with ventilation duration and ICU length of stay also recorded at ICU discharge by a blinded assessor. RESULTS: Fourteen of 20 participants survived to ICU discharge (8, intervention; 6, control). One control was transferred before extubation, while one withdrew consent and one was withdrawn for staff safety after extubation. Median compliance to stimulation sessions was 92.1% (IQR 5.77%) in the intervention group, and 97.2% (IQR 7.40%) in the control group (p = 0.384). While this pilot study is not adequately powered to make an accurate statistical conclusion, there appeared to be no between-group thickness changes of the rectus abdominis (p = 0.099 at day 3), diaphragm (p = 0.652 at day 3) or combined lateral abdominal muscles (p = 0.074 at day 3). However, ICU length of stay (p = 0.011) and ventilation duration (p = 0.039) appeared to be shorter in the intervention compared to the control group. CONCLUSIONS: Our compliance rates demonstrate the feasibility of using abdominal FES with critically ill mechanically ventilated patients. While abdominal FES did not lead to differences in abdominal muscle or diaphragm thickness, it may be an effective method to reduce ventilation duration and ICU length of stay in this patient group. A fully powered study into this effect is warranted. TRIAL REGISTRATION: The Australian New Zealand Clinical Trials Registry, ACTRN12617001180303. Registered 9 August 2017.

Rezoning Free Muscle-Sparing Transverse Rectus Abdominis Myocutaneous Flaps Based on Perforasome Groupings and a New Understanding of the Vascular Architecture of the Deep Inferior Epigastric Artery-Based Flaps.

BACKGROUND: We compare the vascular territory of free muscle-sparing transverse rectus abdominis myocutaneous (MS-TRAM) flaps, deep inferior epigastric perforator (DIEP) flaps, and crossover anastomosis (CA) flaps using intraoperative ex vivo angiography. We also use ex vivo angiography to analyze the vascular architecture of the MS-TRAM flap. METHODS: Our study includes 84 lower abdominal free flaps: MS-TRAM, DIEP-1 (1 perforator), DIEP-2 (2 perforators), and CA. We compare the arterial perfusion area and vascular territory pattern in each group. We also analyze the vascular architecture in MS-TRAM flaps and determine the number and location of their dominant perforators and the direction of the axial arteries connecting them. RESULTS: The CA's arterial perfusion area is the largest, and the DIEP-1's, the smallest of our groups; there is no statistically significant difference between MS-TRAM and DIEP-2. In all groups, average arterial perfusion area in the vascular pedicle's ipsilateral side is larger than in its contralateral side. The MS-TRAM and DIEP-2 flaps have homologous perfusion patterns and the same arterial perfusion areas. The DIEP-1 perfusion pattern varies with perforator location. Ex vivo angiograms show the MS-TRAM flap's axial arteries heading laterally to be larger and longer than those heading medially. CONCLUSIONS: Two dominant perforators are preferable in DIEP flap breast reconstruction. Lateral perforators play a more important role in flap perfusion than do medial ones. Crossover anastomosis is an effective technology for increasing arterial perfusion areas. Our rezoning shows which areas are better for surgery and which have a high risk of complications-valuable information for a surgeon designing a flap for breast reconstruction.

Contralateral unaffected breast augmentation using zone IV as a SIEA flap during unilateral DIEP flap breast reconstruction.

BACKGROUND: Contralateral breast augmentation during unilateral breast reconstruction is a good option for women with small breasts. In patients with adequate lower abdominal tissues, the deep inferior epigastric perforator (DIEP) flap is often the first choice for unilateral autologous breast reconstruction. We use Zone IV, which is usually excised owing to its insufficient blood circulation, as a superficial inferior epigastric artery (SIEA) flap for contralateral breast augmentation. METHODS: Between October 2004 and January 2016, 32 patients underwent unilateral breast reconstruction using a DIEP flap and an attempted simultaneous contralateral breast augmentation with an SIEA flap. The unilateral DIEP flap attached to the contralateral SIEA flap was split into two separate flaps after indocyanine green angiography. In all patients, ipsilateral internal mammary vessels were used as recipient vessels for DIEP flap breast reconstruction. The SIEA flap pedicle was anastomosed to several branches of the deep inferior epigastric vessels. The SIEA flap was inset beneath the contralateral breast through the midline. RESULTS: Of 32 patients, 27 underwent DIEP flap breast reconstruction and simultaneous unaffected breast augmentation using 25 SIEA or 2 superficial circumflex iliac artery perforator (SCIP) flaps. All DIEP flaps survived, and total necrosis occurred in one SIEA flap. The mean weight of the final inset for DIEP flap reconstruction and SIEA or SCIP flap augmentation was 416 g and 112 g, respectively. CONCLUSIONS: Unilateral DIEP flap breast reconstruction and contralateral SIEA flap breast augmentation may be safely performed with satisfactory results.