Umbilical Complications following DIEP Flap Breast Reconstruction: Demonstrating the Added Benefit of Preoperative Imaging.

BACKGROUND: Despite the umbilicus being an essential aesthetic unit, current literature on umbilical outcomes following abdominally based breast reconstruction is limited. In this study, the authors aim to elucidate the incidence and predictors of umbilical complications following deep inferior epigastric perforator (DIEP) flaps, with a particular emphasis on past abdominal surgery by type and measures that can be obtained easily from preoperative imaging. METHODS: An institutional review board-approved retrospective review of 258 patients who underwent DIEP flap reconstruction from 2011 through 2020 was performed. Patient demographics, preoperative laboratory studies, and intraoperative factors were appraised. Preoperative computed tomographic angiography or magnetic resonance angiography was used to measure umbilical stalk height (SH), abdominal wall thickness (AWT), and total fascial diastasis. Patients with and without perfusion-related umbilical complications were compared. RESULTS: Forty patients (15.5%) developed umbilical complications, including 20 patients with epidermolysis or scab, 12 with dehiscence, and 14 with partial necrosis. Patients with complications had a significantly higher rate of hypertension, previous abdominal midline incision, more lateral perforators per flap, longer umbilical stalk, and larger SH/AWT ratio ( P < 0.05). Logistic regression revealed that SH ( P = 0.006) and SH/AWT ratio ( P < 0.001) were the only significant predictors, with the latter having a greater area under the receiver operating characteristic curve (area under the curve, 0.79; P < 0.001). CONCLUSIONS: Radiographic measurements of umbilical SH and SH/AWT ratio reliably predict the occurrence of umbilical complications, with the ratio having a more robust predictive ability. The authors propose the use of routine preoperative imaging to identify high-risk patients who may benefit from prophylactic measures. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

The Superficial Circumflex Iliac Artery Perforator Flap in Lower Extremity Reconstruction.

The superficial circumflex iliac artery perforator flap is evolved from the groin flap, which was one of the early free flaps with a good concealed donor site. By further understanding the anatomy of perforators and elevating the flap based on it, this will provide added advantage of being a thin flap, harvesting as a composite flap, and help estimate the limit of skin paddle dimension. Despite these advantages, the relatively short pedicle still remains a challenge where long pedicle flaps are needed. One should select the flaps based on the recipient defect condition along with surgeons' experience, knowledge, and preference.

Setting up a new microsurgical breast service in a non-tertiary hospital: Is it safe, and do outcomes compare to centres of excellence?

AIMS: Access to autologous reconstruction continues to be limited in some areas of the United Kingdom. This is, in part, due to the perceived difficulty offering this service outside of a large tertiary centre. We present our experience setting up a new microsurgical breast reconstruction service in a district hospital and compare our results to the published outcomes of large volume centres. METHODS: Patient data were collected prospectively from the start of the service to date (July 2018- July 2020) with the capture of demographics, management, and outcomes. The BREAST-Q tool was used preoperatively and at a minimum of 3 months. RESULTS: The first 40 patients undergoing DIEP reconstruction were included. Of these, 70% were immediate, mean age was 49 years (27-68) and BMI was 28.1 kg/m2 (22-32.5). In all, 50% had one or more co-morbidities other than breast cancer. Median length of stay was 3 days (2-6) with 75% of patients discharged on day 2 or 3. Ten patients' stay exceeded 3 days - mostly due to social reasons. Flap loss occurred in 1 patient (2.5%). Twenty-one patients developed complications (52%) within 90 days: seven Clavien-Dindo Grade I, two Grade II and ten Grade IIIb. Fat necrosis and mastectomy flap necrosis were the most common complications. Surgical intervention was higher in those needing adjuvant therapy. Patient-reported outcomes showed post-operative improvement across all domains except abdominal physical well-being at median 11.3 months. CONCLUSIONS: We present the shortest published length of stay for unilateral DIEP reconstructions. We are the first paper to publish patient-reported outcomes following a breast microsurgical enhanced recovery protocol. We demonstrate how a new microsurgical service, utilising an enhanced recovery protocol and careful patient selection can immediately achieve outcomes comparable to well-established centres. There is no reason why all patients should not have access to microsurgical breast reconstruction locally.

Indocyanine Green Angiography Predicts Tissue Necrosis More Accurately Than Thermal Imaging and Near-Infrared Spectroscopy in a Rat Perforator Flap Model.

BACKGROUND: Clinical examination alone is neither sensitive nor specific for predicting flap necrosis, so several technologies, including indocyanine green angiography, thermal imaging (using the FLIR ONE), and near-infrared spectroscopy, have been developed to supplement perfusion assessment. This study aims to compare the accuracy of these three methods for intraoperatively predicting clinical flap necrosis in a rat perforator flap model. The authors hypothesized that near-infrared spectroscopy, assessing oxygenation rather than direct perfusion, would yield significantly different predictions. METHODS: A 10 × 3-cm epigastric perforator flap was elevated in 14 adult male rats weighing 250 ± 50 g. Flap perfusion was assessed immediately after flap elevation using thermal imaging, near-infrared spectroscopy, and indocyanine green angiography. Measurements were correlated to the clinical endpoint and gold standard of flap necrosis on postoperative day 7. RESULTS: All three technologies detected significant differences in perfusion along flap length (all p < 0.001), and were associated with significant differences in the odds of developing flap necrosis (all p < 0.001). The areas under the receiver operating characteristic curves were 0.948 for indocyanine green angiography as an absolute value, 0.873 for relative changes with thermal imaging, and 0.792 for tissue oxygenation. The sensitivity, specificity, and accuracy for indocyanine green angiography measured as an absolute value were the highest at 97.8, 87.5, and 92 percent, respectively. CONCLUSIONS: Indocyanine green angiography most accurately predicted flap necrosis in this study; however, tissue oximetry and thermal imaging were also capable of predicting necrosis and represented potentially less expensive or more readily available alternatives for objective perfusion assessment. Additional research can further delineate their roles and cost-efficacy in clinical practice.

Profunda femoris artery perforator flaps: a detailed anatomical study.

The thigh region has many perforators when compared to the other areas in the body. Surgeons have disregarded the posterior thigh region as a potential donor site for perforator flap surgeries, presumably owing to the positioning difficulties of the patients during the intervention and inadequate anatomical information. The purpose of this study was to provide comprehensive data concerning the profunda femoris artery. Perforator flaps on an anatomical basis, and to describe anatomical landmarks, easing topographical flap dissection in various combinations. Eleven fresh cadaver thighs were obtained from different individuals using the Willed Body Program. The mean age was 43.5 years (29-63), and the male/female ratio was 7/4. We evaluated each cutaneous perforator for localization, diameter, source artery, numbers, length, and type (musculocutaneous or septocutaneous).We observed at least two perforators in all thighs in the study. Medial perforators consisted of 74.5% musculocutaneous and 25.5% septocutaneous perforators. Lateral perforators consisted of 68.3% septocutaneous perforators and 31.7% musculocutaneous perforators. Positioning difficulties of the patient during surgery and inadequate anatomical information cause surgeons to avoid this area. However, surgeons may easily perform these flaps in reconstructive surgery as a local or free flap with substantial success.

Microsurgical Phalloplasty in Nontranssexual Patients - Considerations After a Retrospective Single-center Analysis of 23 Cases.

OBJECTIVE: To evaluate the outcome of a single-center series of penile reconstruction using the radial free forearm flap in rare indications. MATERIALS AND METHODS: From April 1993 until September 2016, 23 nontranssexual patients underwent phallic reconstruction by the use of a neuromicrovascular free radial forearm flap in our clinic. Patient-specific characteristics, surgical techniques, complications, and outcomes were retrospectively evaluated and interpreted. RESULTS: The indications for surgery were: disorders of sex development (34.8%), reconstruction after oncologic surgery (34.8%), automutilation (8.7%), iatrogenic (8.7%), microphallus (8.7%), and 1 case of priapism (4.3%). Two patients (8.7%) had a total flap necrosis and 2 patients (8.7%) had a partial flap necrosis; 3 out of these 4 patients were heavy smokers. Urinary fistulae and strictures were frequent but were successfully managed by urologists in all cases. There was no statistically significant correlation between smoking, comorbidities, number of venous anastomoses, and complications. CONCLUSION: In departments experienced in microsurgery, the goals of penile reconstruction could also be achieved in patients with rare indications by the use of the neuromicrovascular free radial forearm flap. Despite the high rate of postoperative complications, penile reconstruction with the free radial forearm flap yields satisfying results. An intensive cooperation between the plastic-reconstructive team and the urological team is a prerequisite to achieve the best surgical result.

Arterial Supercharging Is More Beneficial to Flap Survival Due to Quadruple Dilation of Venules.

BACKGROUND: "Choke vessels" are communicating conduits between adjacent perforasomes in the skin. Most researches focus mainly on the arterial aspect of the "choke vessels" and neglect the venous aspect, an imbalance needed to be addressed. MATERIALS AND METHODS: The study was divided into parts I, II, and III. Part I was for observation of the vascular morphological evolution in the choke zone after flap harvest in rats. Part II was for determination of the importance of the dilation of the arterial and venous components of "choke vessels" by preserving the iliolumbar artery (ILA group) or vein (ILV group). A laser Doppler flowmeter and a speckle flow imaging system were adopted for monitoring the hemodynamic impact caused by the different manipulation. Part III was for corroboration of part II by manipulation of other vessels. RESULTS: In part I, the arteries and veins between the iliolumbar and intercostal perforasomes underwent modest dilation, whereas the venules between the veins nearly quadrupled in diameter. In part II, flaps in the ILA group were much more intensive in blood perfusion than flaps in the ILV group. The flap necrosis rate was 0.31 ± 0.07 in the ILV group, being significantly larger than 0.10 ± 0.03 in the ILA group. Part III confirmed that venous superdrainage is less efficacious in reducing flap necrosis than arterial supercharging, in which the position of the additional artery was far more important than the diameter. CONCLUSIONS: The extensive dilation of the venous component of choke vessels makes a more potent compensatory role for venous drainage after flap harvest, indicating arterial supercharging is better in augmenting flap viability than venous superdrainage.

Body mass index and abdominal wall thickness correlate with perforator caliber in free abdominal tissue transfer for breast reconstruction.

INTRODUCTION: The aim of the study was to investigate the relationship of BMI and abdominal wall thickness (AWT) with the diameter of the dominant deep inferior epigastric artery perforator (DIEP) as well as DIEA branching pattern in preoperatively performed computed tomography angiography (CTA). PATIENTS AND METHODS: We conducted a retrospective study including all patients undergoing DIEP flap breast reconstruction with available CTAs from November 2013 to April 2018 in our department. The caliber-strongest DIEP was detected after passage of the rectus fascia as well as the superficial inferior epigastric artery (SIEA) and correlated with the AWT 5 cm above and below the umbilicus, lateral at the level of the umbilicus and at the level of the anterior superior iliac spine (ASIS), and with BMI. RESULTS: Seventy-seven patients met the inclusion criteria (age: 47.3 ± 8.9 years). We observed a significant relationship (p < 0.05) between DIEP (mean ∅ = 2.98 mm) and BMI (r = 0.353), the AWT supra- and infraumbilical (r ≥ 0.32), and the AWT lateral at the level of the umbilicus and ASIS (r ≥ 0.25). In addition, there was a highly significant correlation (p < 0.01) between SIEA and BMI (r = 0.389) and between the AWT lateral at the level of ASIS (r ≥ 0.41). CONCLUSION: We demonstrated a correlation of the diameter of the dominant DIEP with both BMI and AWT. Focusing on the diameter, in patients with a high AWT at the level of the ASIS, the SIEA, if present, may represent an alternative therapeutic option.

Extracorporeal Free Flap Perfusion Using Extracorporeal Membrane Oxygenation Device: An Experimental Model.

Extracorporeal perfusion of organs has a wide range of clinical applications like prolonged vital storage of organs, isolated applications of drugs, bridging time to transplant, and free composite tissue transfer without anastomosis, but there are a limited number of experimental models on this topic.This study aimed to develop and evaluate a human extracorporeal free flap perfusion model using an extracorporeal membrane oxygenation device. Five patients undergoing esthetic abdominoplasty participated in this study. Deep inferior epigastric artery perforator flaps were obtained abdominoplasty flaps, which are normally medical waste, used in this model. Deep inferior epigastric artery perforator flaps were extracorporeally perfused with a mean of 6 days. The biochemical and pathological evaluations of the perfusions were discussed in the article.

A Preliminary Study of the Effects of Venous Drainage Position on Arterial Blood Supply and Venous Return within the Conjoined Flap.

BACKGROUND: Conjoined flap viability is associated with arterial blood supply and venous return. This study aimed to assess the effects of venous drainage position on arterial blood supply and venous return within the conjoined flap. METHODS: Fifty-four rats were divided randomly into three groups (n = 18 per group). In experimental group 2, only the right intercostal posterior artery and the left iliolumbar vein were maintained; meanwhile, only the right intercostal posterior artery and the left intercostal posterior vein were preserved in experimental group 1. The control group had only the right intercostal posterior artery and vein preserved. The distances between angiosomes were measured. At 7 days after surgery, flap survival was evaluated, lead oxide-gelatin flap angiography was performed, and average microvessel density was assessed by hematoxylin and eosin staining, and lactate levels were assessed. RESULTS: The distance between angiosomes I and II was the shortest, whereas angiosomes I and III were most distant (p < 0.05). At 7 days after surgery, survival rates in experimental group 2 and experimental group 1 were both 100 percent, whereas 86.5 ± 1.6 percent of controls survived. Furthermore, angiogenesis was more obvious in experimental group 2 than in experimental group 1 and controls. Moreover, lactate levels were lower in experimental group 2 (7.47 ± 0.17 mM) and experimental group 1 (8.03 ± 0.31 mM) compared with control values (9.98 ± 0.37 mM; p < 0.05). CONCLUSION: Changes in position of venous drainage might cause continuous arterial high-pressure perfusion and venous superdrainage, which improves flap survival.

Augmented Reality Microsurgical Planning with a Smartphone (ARM-PS): A dissection route map in your pocket.

INTRODUCTION: Perioperative microsurgical planning increases the likelihood of successful results. Augmented reality (AR) is the addition of artificial information to allow the user to perform tasks more efficiently. The aim of our study is to report the use of AR for microsurgical planning with a smartphone (ARM-PS) as a dissection route map. PATIENTS AND METHODS: AR was used for superficial circumflex iliac artery perforator (SCIP) flap planning. Three-dimensional (3D) reconstruction images of the inguinal and lower abdomen vascular anatomy were obtained by computed tomography angiography. These 3D images were imported to a smartphone and an AR app was used to superimpose them with the camera. The drawings performed with ARM-PS were correlated with handheld Doppler and intraoperative findings. RESULTS: The correlation of ARM-PS drawings with handheld Doppler results was 100% for superficial inferior epigastric artery (SIEA) and superficial and deep branches of SCIP in 60 inguinal areas studied. Intraoperative findings matched perfectly in all 30 cases with ARM-PS drawings for the location of the mentioned vessels and lymph nodes. Flap harvest time decreased in 20% compared with our traditional timing. CONCLUSIONS: ARM-PS is an easy, noninvasive, and accurate method that provides a dissection route map, thereby standardizing flap harvesting, and shows a perfect correlation with intraoperative findings. It reduces operating time and may improve operative results, thus decreasing donor site morbidity.

The adipofasciocutaneous gluteal fold perforator flap a versatile alternative choice for covering perineal defects.

AIM: Perineal defects following the resection of anorectal malignancies are a reconstructive challenge. Flaps based on the rectus abdominis muscle have several drawbacks. Regional perforator flaps may be a suitable alternative. We present our experience of using the gluteal fold flap (GFF) for reconstructing perineal and pelvic defects. METHODS: We used a retrospective chart review and follow-up examinations focusing on epidemiological, oncological (procedure and outcome), and therapy-related data. This included postoperative complications and their management, length of hospital stay, and time to heal. RESULTS: Twenty-two GFFs (unilateral n = 8; bilateral n = 7) were performed in 15 patients (nine women and six men; anal squamous cell carcinoma n = 8; rectal adenocarcinoma n = 7; mean age 65.5 + 8.2 years) with a mean follow-up time of 1 year. Of the cases, 73.3% were a recurrent disease. Microscopic tumor resection was achieved in all but one case (93.3%). Seven cases had no complications (46.7%). Surgical complications were classified according to the Clavien-Dindo system (grades I n = 2; II n = 2; IIIb n = 4). These were mainly wound healing disorders that did not affect mobilization or discharge. The time to discharge was 22 + 9.9 days. The oncological outcomes were as follows: 53.3% of the patients had no evidence of disease, 20% had metastatic disease, 20% had local recurrent disease, and one patient (6.7%) died of other causes. CONCLUSIONS: The GFF is a robust, reliable flap suitable for perineal and pelvic reconstruction. It can be raised quickly and easily, has an acceptable complication rate and donor site morbidity, and does not affect the abdominal wall.

Simultaneous deep inferior epigastric and bilateral anterolateral thigh perforator flap reconstruction of an extended perineoscrotal defect in Fournier's gangrene: A case report.

Fournier's gangrene is lethal necrotizing fasciitis that involves the perineum and external genitalia. We describe the case of a 52-year-old man with Fournier's gangrene who underwent reconstruction of an extensive perineoscrotal defect using three pedicled perforator flaps. Three debridement procedures resulted in a skin and soft tissue defect of 36 × 18 cm involving the perineum, scrotum, groin, medial thigh, buttocks, and circumferential perianal area and left the perforating arteries originating from these locations unavailable for reconstruction. We repaired the defect using left deep inferior epigastric artery perforator (DIEP) (29 × 8 cm) and bilateral anterolateral thigh perforator (ALT) flaps (35 × 8 cm and 22 × 7 cm). The flaps reached the defect without tension, and the defect was successfully covered without a skin graft. No postoperative complications occurred except for epidermal necrosis involving a tiny part of the DIEP flap tip. Nine months postoperatively, the patient experienced no impairment of bowel function or hip joint movement. There was also no avulsion or ulceration of the reconstructed perineal skin, and the cosmetic appearances of the healed wound and donor site were satisfactory. The combination of these three perforator flaps enabled us to achieve a satisfactory outcome while avoiding skin grafts.

The hemodynamic and molecular mechanism study on the choke vessels in the multi-territory perforator flap transforming into true anastomosis.

BACKGROUND: The aim of this study was to explore the hemodynamic and morphological changes of the choke vessels, and to investigate the role of HIF-1α in the flap adaptation to hypoxic and choke vessel transformation after multi-territory perforator flap transplantation. METHODS: Animal model of single pedicle multi-territory perforator flap was established in the back of SD rats and the blood supply characteristics were studied by gelatin-oxide perfusion technique. HE staining and stereomicroscope were used to observe vascular changes. Afterward, the influence of hypoxia on cell proliferation and apoptosis were detected by MTT assay and flow cytometry, respectively. Besides, the expression of HIF-1α, iNOS and VEGF expression of HUVECs under hypoxia were detected by qRT-PCR and Western blot. RESULTS: The results revealed that all the choke vessels immediately began to expand after operation. The day after operation, some of the choke vessels continued to grow and expand, turning into the true anastomosis, while the others gradually dwindled and finally disappeared. Compared with the control group, the day after transplantation, the expression levels of both HIF-1α and iNOS were significantly increased. The only different was that HIF-1α was then maintained a high level, iNOS was significantly decreased aftertimes. What's more, the expression of VEGF was increased to the maximum at 3 days after operation and then decreased. In HUVECs, hypoxia increased the expression of HIF-1α, iNOS and VEGF protein. Besides, it also promoted the proliferation and inhibited the apoptosis. In addition, we also found that hypoxia-induced VEGF and iNOS upregulation is mediated by HIF-1α overexpression and HIF-1α knockout can reverse the effects induced by hypoxia. CONCLUSIONS: We found that HIF-1α may participate in the early vascular dilatation of transregional skin flap by inducing iNOS expression and promoting the reconstruction of choke vessels through increase VEGF expression.

Comparative Study of Choke Vessel Reconstruction With Single and Multiple Perforator-Based Flaps on the Murine Back Using Delayed Surgery.

OBJECTIVE: Choke vessels, vascular anastomosis between adjacent angiosome, play an important role in flap expansion and survival. Here we established a flap model with single and multiple perforators to detect and compare the changes in choke vessels, discuss the effect of hemodynamics on the vascular morphology, and explore the underlying mechanism. METHODS: One hundred mice (7-8 weeks) were subjected to a "choke zone" surrounded by 4 perforators on their backs. Delayed surgery was performed by the ligation of 1, 2, or 3 perforators to establish flap models. The blood flow of the choke zone was measured by laser Doppler flowmetry preoperatively and 6 hours and 1, 3, 5, and 7 days. The morphological changes of choke vessels in the choke zone were observed by gross and histological analyses. Levels of angiogenesis-related markers such as endothelial nitric oxide synthase (eNOS), metalloproteinase 2, hypoxia-inducible factor 1α (HIF-1α), and intercellular adhesion molecule 2 (ICAM-2) were detected by Western blotting and enzyme-linked immunosorbent assay. RESULTS: Blood flow and microvascular count were obviously increased postoperatively and peaked and were maintained for 1 week (P < 0.01). Meanwhile, the diameters of the choke vessels expanded. The eNOS level was increased at 7 days (P < 0.05); however, the enzyme-linked immunosorbent assay results showed that the HIF-1α and ICAM-2 levels were decreased at 7 days. CONCLUSIONS: (1) The delayed surgery that kept a single perforator had the greatest impact on the choke zone. (2) Changes in choke vessels were closely related to the shear stress caused by enhanced blood perfusion after surgery. (3) Choke vessel growth was regulated by eNOS, metalloproteinase 2, HIF-1α, and ICAM-2.

Intraoperative Indocyanine Green Angiography for Fat Necrosis Reduction in the Deep Inferior Epigastric Perforator (DIEP) Flap.

BACKGROUND: Fat necrosis is a frequent complication (up to 62.5%) of microsurgical breast reconstruction using the deep inferior epigastric perforator (DIEP) flap. This could have important clinical and psychological repercussions, deteriorating the results and increasing reconstruction costs. OBJECTIVES: The aim of this study was to demonstrate the intraoperative use of indocyanine green angiography (ICGA) to reduce fat necrosis in DIEP flap. METHODS: Sixty-one patients who underwent unilateral DIEP flap procedures for breast reconstruction after oncological mastectomy were included (24 cases with intraoperative use of ICGA during surgery, 37 cases in the control group). The follow-up period was 1 year after surgery. The association between the use of ICGA and the incidence of fat necrosis in the first postoperative year, differences in fat necrosis grade (I-V), differences in fat necrosis requiring reoperation, quality of life, and patient satisfaction were analyzed. RESULTS: The incidence of fat necrosis was reduced from 59.5% (control group) to 29% (ICG-group) (P = 0.021) (relative risk = 0.49 [95% CI, 0.25-0.97]). The major difference was in grade II (27% vs 2.7%, P = 0.038). The number of second surgeries for fat necrosis treatment was also reduced (45.9% vs 20.8%, P = 0.046). The ICG group had higher scores on the BREAST-Q. CONCLUSIONS: Intraoperative ICGA is a useful technique for reconstructive microsurgery that might improve patient satisfaction and reduce the incidence of fat necrosis by half as well as reduce its grade, especially in small fat necrosis cases; consequently, ICGA could reduce the number of secondary surgeries for treatment of fat necrosis.

Posterior intercostal artery perforator flap for posterior trunk reconstruction: Perforator mapping with high-resolution ultrasound and clinical application.

BACKGROUND: Pedicled perforator flaps have progressively been used for reconstructive purposes of the anterior trunk. However, reports regarding perforator flaps for local reconstruction of the posterior trunk are sparse. The aim of this study was to investigate the vascular basis of perforator flaps based on the posterior intercostal arteries and to highlight the clinical versatility of these flaps for local posterior trunk reconstruction. METHODS: The posterior intercostal artery perforators (PICAP) between the 4th and 12th intercostal space were investigated using high resolution ultrasound in ten healthy volunteers. The location, diameter, suprafascial length and course of the individual perforators was measured. PICAP flaps were used in a series of ten cases for defect reconstruction of the posterior trunk to demonstrate their clinical versatility. RESULTS: A total number of 100 perforators was investigated. The mean diameter was 0,7 ±â€¯0,24 mm with an average length until arborisation of 0,8 ±â€¯0,8 cm. Perforators were located at 2,4 ±â€¯1,8 cm from the midline on average. Only 16% of all measured perforators were identified as major perforators (diameter ≥ 1 mm). In ten patients (mean age at surgery 61,7 years, f:m = 3:7) a PICAP flap was used for defect reconstruction at the back with a mean follow-up of 2,9 years. Flap dimensions ranged from 7 × 3 to 16 × 7 cm. In three cases, a complication was observed (one seroma, one hematoma, one marginal tip necrosis). CONCLUSION: In the present study, a reliable vascular basis of the posterior intercostal artery perforator flap could be demonstrated. Clinically these flaps replace "like with like" and may be transposed in a propeller - or V to Y - fashion. The donor site can be closed primarily in most cases, thus resulting in a favorable donor side morbidity.

How to assess the volume of a DIEP flap using a free online calculator: The DIEP V (volume) method.

INTRODUCTION: Among the few methods available, none is able to determine accurately the volume of a DIEP flap. Specimen weight is commonly used to assess the amount of flap needed to reconstruct a breast, but the density of breast is different from that of abdominal tissues; therefore, the volume should be used as a unique unit of measure. The purpose of this study was to provide a simple method to calculate the predicted volume of a DIEP flap in order to match the volume of the breast being reconstructed. MATERIAL AND METHOD: We hypothesised that the shape best resembling a DIEP flap was a truncated pyramid. Based on this shape, we tailored 30 DIEP flap models using the discarded tissue after unilateral DIEP flap breast reconstructions. The awaited volume (AV) of the models was calculated with a free online calculator measuring the length and height with a ruler, and width (fat thickness) with Ultrasound (US). The real volume (RV) of the models was calculated using water displacement method. AV and RV were compared and statistical analysis was performed. RESULTS: The mean difference between the AV and the RV was not statistically significant with a mean estimation error of 6.75%. When the AVs were plotted against the RVs, the two data sets were highly statistically correlated (correlation coefficient (r = 0.997). CONCLUSIONS: The proposed tool can be a useful, precise, easy and accessible tool to improve the current DIEP flap size assessment improving outcomes for both surgeons and patients.

Optimizing Perforator Selection: A Multivariable Analysis of Predictors for Fat Necrosis and Abdominal Morbidity in DIEP Flap Breast Reconstruction.

BACKGROUND: This study aims to elucidate the important predicting factors for fat necrosis and abdominal morbidity in the patient undergoing deep inferior epigastric artery perforator flap reconstruction. METHODS: The authors conducted a retrospective review of 866 free-flap breast reconstructions performed at one institution from 2010 to 2016. Twenty-eight potential predictors were included in multivariable analyses to control for possible confounding interactions. RESULTS: Four hundred nine total deep inferior epigastric artery perforator flaps were included in the statistical analysis. Of these, 14.4 percent had flap fat necrosis, 21.3 percent had an abdominal wound or complication, and 6 percent had an abdominal bulge or hernia. Analysis showed an increase in the odds of fat necrosis with increasing flap weight (OR, 1.002 per 1-g increase; p = 0.0002). A decrease in the odds of fat necrosis was seen with lateral row (OR, 0.29; p = 0.001) and both medial and lateral row perforator flaps (OR, 0.21; p = 0.001), if indocyanine green angiography was used (OR, 0.46; p = 0.04), and with increasing total flow rate of the flap (OR, 0.62 per 1-mm/second increase; p = 0.05). Increased odds of abdominal bulge or hernia were seen with lateral row or both medial and lateral row perforators (OR, 3.21; p = 0.05) versus medial row perforator-based flaps, and with patients who had an abdominal wound postoperatively (OR, 2.59; p = 0.05). CONCLUSIONS: The authors' results suggest that using larger caliber perforators and perforators from the lateral row alone, or in addition to medial row perforators, can decrease fat necrosis more than simply harvesting more perforators alone. However, lateral and both medial and lateral row perforator flaps come at the cost of increasing abdominal bulge rates. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Three-dimensional Analysis of How Radiation Affects Deep Inferior Epigastric Perforator (DIEP) Flap Volume, Projection, and Position in Breast Cancer Reconstruction.

BACKGROUND: The deep inferior epigastric perforator (DIEP) flap has gained popularity for autologous free flap breast reconstruction. Historically, patients receiving post mastectomy radiation therapy (PMRT) were not candidates for immediate autologous reconstruction due to concerns for flap volume depletion, fat necrosis, and flap failure. However, this literature is anecdotal and lacks case controls. We objectively analyzed the effects radiation imparts on immediate DIEP flap reconstruction using 3-dimensional software and inherent controls. METHODS: We performed a cohort study on breast cancer patients who underwent immediate bilateral DIEP flap reconstructions followed by PMRT between 2005 and 2014. Exclusion criteria included patients less than 6 months from PMRT completion and bilateral PMRT. Three-dimensional photographs were analyzed using Geomagic (Rock Hill, SC) software to compare flap position, projection, and volume between the irradiated and nonirradiated reconstructed breasts. Breast Q survey evaluated patients' satisfaction. RESULTS: Eleven patients met inclusion criteria. Average time from PMRT completion to photo acquisition was 1.93 years. There was no statistical difference in average volume or projection in the irradiated versus nonirradiated side (P = 0.087 and P = 0.176, respectively). However, position of the irradiated flaps was significantly higher on the chest wall compared to controls (mean difference, 1.325 cm; P < 0.004). CONCLUSIONS: Three-dimensional analysis exhibited no statistical differences in projection or volume between irradiated DIEP flaps and nonirradiated controls. However, irradiated DIEP flaps were positioned higher on the chest wall, similar to observations in irradiated tissue expanders/implants. Patients were satisfied as measured by Breast Q. Immediate bilateral DIEP flap reconstructions can safely be performed with PMRT with satisfactory results.