Secondary solution for breast reconstruction following total DIEP flap loss: A single-center experience after 3270 DIEP flaps.

BACKGROUND: Total deep inferior epigastric perforator (DIEP) flap failure is a significant concern in autologous breast reconstruction. Literature on secondary reconstruction options following total flap failure is limited. This study outlines the outcomes of patients who underwent reconstruction post-DIEP flap failure at our institution. METHODS: We conducted a retrospective analysis of patients receiving autologous breast reconstruction between 2004 and 2021. We aimed to identify causes of total DIEP flap failure, outcomes of revision surgery, and outcomes of secondary breast reconstruction procedures. RESULTS: From 2004 to 2021, 3456 free flaps for breast reconstruction were performed, with 3270 being DIEP flaps for 2756 patients. DIEP flap failure was observed in 40 cases (1.22%). Bilateral reconstructions had a higher failure rate (2.31%) than unilateral (0.72%). The primary cause was intraoperative complications during flap harvest (18 cases), followed by insufficient arterial perfusion (seven cases). Other causes included postoperative hematoma (seven cases), venous congestion (six cases), and late-onset fat necrosis (two cases). Post-failure, five patients received a second free flap with three cases of repeated flap failure. Twenty patients received implant-based reconstruction with two cases of reconstruction failure, while seven patients received a pedicled latissimus dorsi (LD) flap reconstructions with no cases of reconstruction failure. Eight patients declined further reconstruction. CONCLUSION: A second free flap post-DIEP failure was associated with a high risk of reconstruction failure, suggesting the need for careful patient selection. Implant-based and pedicled LD flap seem to be reliable secondary reconstruction options.

Double-Unit Superomedio-Central (DUS) Pedicle Inverted-T Reduction Mammaplasty in Gigantomastia: A 7-year Single-Center Retrospective Study.

INTRODUCTION: Reduction mammaplasty in patients with gigantomastia is challenging. The Double-Unit technique with a Superomedio-Central pedicle and inverted-T incision is the standard technique for reduction mammaplasty in our clinic. The aim of this study was to review our approach in cases with gigantomastia in comparison with the current literature. PATIENTS AND METHODS: From 01/2011 to 12/2017, we performed 831 reduction mammaplasties in 630 patients. The Double-Unit  Superomedio-Central  (DUS) pedicle and inverted-T incision was implemented as a standard procedure for gigantomastia. Patient demographics and the outcome parameters complication rate, patient satisfaction with the aesthetic result, nipple sensibility, and surgical revision rate were obtained and retrospectively analyzed. RESULTS: In 37 patients, 55 reduction mammaplasties were performed with more than 1000 g per breast. Mean resection weight was 1311 g on right side and 1289 g on left side. Mean age was 52.5 years, mean body mass index was 32.8 kg/m2, mean sternal-notch-to-nipple distance was 38.3 cm. A free NAC graft was necessary in four breasts. Overall complication rate was 14.5%; secondary surgical revision rate was 12.7%. 91% of the patients were "very satisfied" and "satisfied" with the aesthetic result. Nipple sensibility was rated "high" and "medium" in 83%. CONCLUSION: The Double-Unit technique with a Superomedio-Central pedicle and inverted-T incision is very effective to achieve volume reduction and aesthetically pleasing reproducible results with a low complication rate in cases with gigantomastia. LEVEL OF EVIDENCE: Level of Evidence 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 .

Myosonographic study of abdominal wall dynamics to assess donor site morbidity after microsurgical breast reconstruction with a DIEP or an ms-2 TRAM flap.

BACKGROUND: Currently, autologous breast reconstruction with a free tissue transfer from the lower abdomen is considered to be a safe method that provides a stable long-term solution. The DIEP-flap and the ms-2-TRAM-flap reconstructions have helped reduce donor site morbidity. In order to assess the potential differences between these techniques, we carried out myosonographic evaluations that assessed the muscle dynamics pre- and post-operatively. In addition to investigating the properties of the rectus abdominis muscle post-operatively, this prospective study also allowed us to analyse the muscle preoperatively and to investigate the prospects for harvesting a DIEP-flap as opposed to a TRAM-flap. MATERIALS AND METHODS: Sixty patients underwent breast reconstruction with 71 (11 bilateral) free abdominal wall flaps (DIEP-: n = 48; ms-2-TRAM-flap: n = 23). Myosonographic examinations were performed preoperatively and at 3 and 6 months post-operatively. The thickness of the muscle at relaxation and maximum contraction and the difference between the muscle thickness measured at the two states were measured. A general-linear-model (GLM) was used for statistical analysis. The main variable was the surgical method, and the co-variables included BMI and patient age. The decision on whether to harvest a DIEP- or ms-2-TRAM-flap was made intra-operatively and based on the dominant perforator. RESULTS: It shows that the patients who underwent breast reconstruction with a DIEP-flap had significantly better muscle function (p < 0.05) in the follow-up. In addition, the analysis revealed that better muscle function before surgery made it more likely that a patient would undergo a DIEP-flap-reconstruction successfully. Patient age also had a highly significant effect on muscle recovery (p < 0.0005). CONCLUSIONS: This prospective study used a dynamic ultrasound evaluation of the abdominal wall and showed that the DIEP-flap significantly reduces donor site morbidity compared to the ms-2-TRAM-flap. The study also showed that good preoperative muscle function might increase the probability of surgeons performing a DIEP-flap reconstruction.

[The DIEP Flap as Method of Choice in Breast Reconstruction - Results and Protocol for Succesful Reconstruction]. / Der DIEP Lappen als Standard in der autologen Brustrekonstruktion - Ergebnisse und Algorithmus zur erfolgreichen Rekonstruktion.

BACKGROUND: Autologous breast reconstruction is becoming increasingly important, especially in light of the increased rates of prophylactic mastectomies with BRCA mutations. Regarding the indications and complications between free TRAM and free DIEP flaps for autologous breast reconstruction the current data is not clear. MATERIALS AND METHODS: All patients who received an autologous breast reconstruction between January 2010 and January 2014 using free DIEP or free MS-2-TRAM flaps were included in the study. The choice of flap between DIEP and MS-2-TRAM was performed by a standardised algorithm with preoperative CT angiography, intraoperative evaluation of the flap perfusion and Doppler detection. The analysis took into account partial flap necrosis <20% and >20%), complete flap loss, flap necrosis and surgical revision of the anastomosis. RESULTS: The study considered 362 women who received a total of 419 free flaps for breast reconstruction. 66 patients received a bilateral reconstruction (52 double DIEPS, 9 DIEP and MS2 TRAM and 5 double MS2 TRAMs). The total flap loss was 0.24%. Partial necrosis <20% occurred in 0.72% (DIEP 0.82%, MS2 TRAM 0%), partial necrosis >20% in 0.72% (DIEP 0.69% MS2 TRAM 0.98%). One DIEP flap was lost (0.24%). After implementing our protocol the rate of MS-2-Tram flaps could be reduced to 10-15% of all autologous breast reconstruction procedures as compared to the years before. CONCLUSION: Through the application of the presented algorithm for breast reconstruction with free DIEP flap, such surgery is a safe treatment option if it is done at high frequency in a microsurgical centre. Flap loss and complications are not increased compared to MS2 TRAM flaps. The decision for the selection of the appropriate flap for breast reconstruction should be based on the presented algorithm in order to achieve secure and reproducible results.