The influence of a previous implant-based breast reconstruction on postoperative sensation of the deep inferior epigastric artery perforator flap.

BACKGROUND: Implants and DIEP flaps have different outcomes regarding postoperative breast sensation. When compared to the preoperative healthy breast, implant-based breast reconstruction (IBBR) negatively influences postoperative breast sensation. However, it is currently unknown whether a prior IBBR also influences postoperative sensation of a replacing DIEP flap. The goal of this cohort study is to evaluate the influence of an IBBR on the postoperative sensation of a replacing DIEP flap. METHODS: Women were included if they received a DIEP flap reconstruction after mastectomy, with or without prior tissue expander (TE) and/or definitive breast implant. Sensation was measured at four intervals in 9 areas of the breast with Semmes-Weinstein monofilaments: T0 (preoperative, implant/no reconstruction), T1 (2-7 months postoperative, DIEP), T2 (± 12 months postoperative, DIEP), Tmax (maximum follow-up, DIEP). Linear mixed-effects models were used to investigate the relationship between an implant/TE prior to the DIEP flap and recovery of breast sensation. RESULTS: 142 women comprising 206 breasts were included. 48 (23.3%) breasts did, and 158 (76.7%) breasts did not have a TE/IBBR prior to their DIEP. No statistically significant or clinically relevant relationships were found between a prior implant/TE and recovery of DIEP flap breast sensation for the flap skin, native skin, or total breast skin at T1, T2, or Tmax. There were also no relationships found after adjustment for the confounders radiation therapy, BMI, diabetes, age, flap weight, follow-up, and nerve coaptation. CONCLUSIONS: An implant/TE prior to a DIEP flap does not influence the recovery of postoperative breast sensation of the DIEP flap.

Transverse division of the rectus abdominis muscle in deep inferior epigastric perforator flap elevation: A rescue technique to include more than one perforator.

BACKGROUND: It is important to include as many perforators as possible in order to enhance the vascularity of a deep inferior epigastric perforator (DIEP) flap. However, the rectus muscle must be transected transversely, which prevents suturing and can cause a defect along the same line as the muscle-sparing procedure. When harvesting the DIEP flap, no specific method was suggested to solve these muscle defects. We found that by transecting the rectus muscle transversely, the muscle could be sutured in the tendinous area more easily while maintaining muscle function. The purpose of this study is to confirm the long-term recovery of the rectus abdominis muscle through the volume change after DIEP flap using this tendinous transection and suture method. PATIENTS AND METHODS: A retrospective review of 28 patients who underwent unilateral breast reconstruction using a DIEP flap and the tendinous transection method for multiple perforators between May 2018 and April 2020 was conducted. The preoperative and postoperative volumes of the rectus abdominis muscle were estimated both the harvest and opposite sides. RESULTS: The preoperative and postoperative muscle volumes from the harvest side were 50.08 ± 8.71 cm3 and 48.56 ± 8.61 cm3, respectively. The volume difference was 1.522 cm3 decrease, which was not statistically significant (p = .070). The preoperative and postoperative muscle volumes from the opposite side were 50.50 ± 8.15 cm3 and 50.08 ± 8.18 cm3, respectively. The volume difference was 0.434 cm3 increase and was not statistically significant (p = .064). Postoperative volume changes in the rectus muscle were not statistically significant on either side. CONCLUSION: The tendinous transection method in the DIEP flap procedure did not significantly affect postoperative rectus muscle volume. Therefore, we expect this harvest method to allow DIEP flap reconstruction that includes multiple perforators and complete donor muscle recovery.

Reversal in Centers for Medicare & Medicaid Services Reimbursement for Deep Inferior Epigastric Perforator Flap Reconstruction-Empowering Plastic Surgeons in Sustaining Microsurgical Accessibility.

ABSTRACT: This Editorial discusses the recent overturning of a proposed Centers for Medicare & Medicaid Services policy that reduced reimbursement for deep inferior epigastric perforator flap breast reconstruction. The authors highlight the importance of advocacy efforts in sustaining access to complex microsurgical procedures, even those under investigation such as breast reinnervation and lymphatic reconstruction.

Efficacy of the enhanced recovery after surgery protocol on reducing surgical disparities related to overweight/obesity in deep inferior epigastric perforator flap breast reconstruction.

BACKGROUND: When choosing a method of deep inferior epigastric perforator (DIEP) flap for breast reconstruction, concerns regarding the potentially detrimental effects of obesity on postoperative recovery remain. Enhanced recovery after surgery (ERAS) is known to facilitate rapid postoperative recovery. This study aimed to examine the effect of the ERAS protocol on the disparity between normal/underweight and overweight/obese patients after DIEP flap breast reconstruction. METHODS: A retrospective review of consecutive patients who underwent DIEP flap breast reconstruction between January 2015 and November 2022 was conducted. The patients were categorized into two groups: pre-ERAS and post-ERAS. In each group, associations between overweight/obese patients (BMI ≥25 kg/m2 ) and postoperative course were evaluated. RESULTS: In total, 217 patients in the pre-ERAS group (including 71 overweight/obese) and 165 in the post-ERAS group (including 58 overweight/obese) were analyzed. The post-ERAS group had shorter length of stay (LOS) (8.0 versus 7.0 days, p-value <.001) and lower postoperative pain scores (5.0 versus 3.0 at postoperative day (POD) 1, p-value <.001) than the pre-ERAS group. The complication profiles did not differ according to ERAS adoption. In the pre-ERAS group, overweight/obese patients showed a significantly longer LOS (8.0 versus 9.0 days, p-value = .017) and a higher postoperative pain score (3.0 versus 4.0 at POD 2, p-value = .018) than normal/underweight patients; however, these differences disappeared in the post-ERAS group, showing similar LOS, pain scores, and analgesic consumption. CONCLUSIONS: Implementation of the ERAS protocol in DIEP free-flap breast reconstruction may reduce overweight/obesity-related disparities in postoperative recovery.

Staged Immediate Nipple Reconstruction With Tube Flap in Immediate Deep Inferior Epigastric Artery Perforator Flap Breast Reconstruction.

BACKGROUND: In the setting of immediate breast reconstruction by deep inferior epigastric artery perforator (DIEP) flap, the excessive DIEP flap skin is de-epithelialized and then buried under the mastectomy skin. In this study, by virtue of tube flap technique, we hypothesize that the skin supposed to be abandoned could be transferred to the apex of reconstructed breast mound for nipple reconstruction. METHODS: A total of 60 female patients were recruited between January 2019 and December 2020. All these patients underwent mastectomy including nipple-areola complex and immediate DIEP flap breast reconstruction. A ladder-shaped pedicled flap was raised from the DIEP flap and rolled into a tube. The free end of tube flap was inset into the future nipple position of the reconstructed breast mound 1 week later. After revascularization for 1 month, we divided the previous pedicle and used the tube on the apex of the breast mound to recreate a new nipple. RESULTS: All reconstructed breasts and nipples survived well postoperatively. The average nipple projection was 12.5 ± 2.0 mm immediately after the surgery, which gradually decreased to 9.4 ± 1.5 mm at 1-year follow-up, with the projection loss from the initial measurement as 24.9% ± 1.8%. In total, 51 patients considered the overall impression of breast and nipple reconstruction to be very good or good. CONCLUSIONS: We provided an ideal technique that could improve the maintenance of reconstructed nipple projection and have aesthetically acceptable outcomes, without DIEP flap tissue loss, breast mound distortion, or additional scars.

Anatomical features of a crossing vein connecting left and right internal mammary veins: A preliminary study with computerized tomography or magnetic resonance imaging.

BACKGROUND: In breast reconstruction with free flaps, retrograde venous anastomosis into the internal mammary vein (IMV) is often unavoidable. Utility of a crossing vein between the right and left IMV, one of the anatomical foundations which make retrograde flow possible, has been reported but only with a few detailed features. This study evaluated the presence, actual location, and diameter of the crossing veins using preoperative imaging such as contrast-enhanced computed tomography (CECT), or contrast-enhanced magnetic resonance imaging (CEMRI). Moreover, this is a preliminary non-invasive study to clarify these processes on a larger scale. METHODS: We included 29 cases of unilateral breast reconstruction performed between July 2018 and September 2023 at our institution using unipedicled or bipedicled free deep inferior epigastric artery perforator (DIEP) flaps with retrograde venous anastomosis to only one IMV at the level of anastomosis. No congestion or necrosis was observed. In the final 24 cases with sufficient imaging coverage of preoperative contrast-enhanced images (15 CECT and 9 CEMRI), the crossing veins of IMVs were detected and the number, localization, and diameter were measured. RESULTS: In 20 cases of 24 images, the crossing veins between IMVs were completely identified (83%). In 18 of the cases, only one crossing vein was established immediately ventral to the xiphoid process, averaging 19.3 ± 7.18 mm caudal to the fibrous junction between the sternal body and xiphoid process. The average diameter of the veins was 1.57 ± 0.42 mm. In two other cases, the second crossing vein originated on the dorsal surface of the sternum, but it was a very thin vein of about 0.4 mm. Three images indicated incomplete identification of the crossing vein at the xiphoid process, and in one case, no crossing vein was observed between bilateral IMVs. CONCLUSION: The contrast-enhanced imaging study revealed an anatomic feature that the crossing veins (about 1.5 mm in diameter) connecting the right and left IMVs are located just ventral to the xiphoid process. Furthermore, the crossing veins can be identified on contrast-enhanced images, and refinement of this method is expected to lead to future non-invasive anatomical investigations in an even larger number of cases.

Abdominal donor-site complications following autologous breast reconstruction: A multi-institutional multisurgeon study.

BACKGROUND: The deep inferior epigastric perforator (DIEP) free flap is the gold standard procedure for autologous breast reconstruction. Although breast-related complications have been well described, donor-site complications and contributing patient risk factors are poorly understood. METHODS: We examined a multi-institutional, prospectively maintained database of patients undergoing DIEP free flap breast reconstruction between 2015 and 2020. We evaluated patient demographics, operative details, and abdominal donor-site complications. Logistic regression modeling was used to predict donor-site outcomes based on patient characteristics. RESULTS: A total of 661 patients were identified who underwent DIEP free flap breast reconstruction across multiple institutions. Using logistic regression modeling, we found that body mass index (BMI) was an independent risk factor for umbilical complications (odds ratio [OR] 1.11, confidence interval [CI] 1.04-1.18, p = 0.001), seroma (OR 1.07, CI 1.01-1.13, p = 0.003), wound dehiscence (OR 1.10, CI 1.06-1.15, p = 0.001), and surgical site infection (OR 1.10, CI 1.05-1.15, p = 0.001) following DIEP free flap breast reconstruction. Further, immediate reconstruction decreases the risk of abdominal bulge formation (OR 0.22, CI 0.108-0.429, p = 0.001). Perforator selection was not associated with abdominal morbidity in our study population. CONCLUSIONS: Higher BMI is associated with increased abdominal donor-site complications following DIEP free flap breast reconstruction. Efforts to lower preoperative BMI may help decrease donor-site complications.

Comparison of complications and functional outcomes following total or subtotal glossectomy with laryngeal preservation using a deep inferior epigastric artery perforator free flap versus a rectus abdominis musculocutaneous free flap.

OBJECTIVE: Wide defects resulting from subtotal or total glossectomy are commonly reconstructed using a bulk flap to maintain oral and speech functions. The flap, including muscle tissue, diminishes with time. This study aimed to compare the surgical outcomes of deep inferior epigastric artery perforator and rectus abdominis musculocutaneous free flap reconstructions after glossectomy with laryngeal preservation. METHODS: Medical records of 13 and 26 patients who underwent deep inferior epigastric artery perforator and rectus abdominis musculocutaneous free flap reconstructions, respectively, from 2014 to 2022 at our institution were reviewed. Patients who underwent middle pharynx resection except for the base of the tongue, mandibular bone resection, and sensory reinnervation were excluded. RESULTS: The rectus abdominis musculocutaneous groups showed a higher number of lymph node dissection and shorter operative time than the deep inferior epigastric artery perforator groups. No significant differences in postoperative complications or functional oral intake scale scores at 6 months were observed. Volumetric changes on computed tomography images at 6 and 12 months were significantly lower in the deep inferior epigastric artery perforator group. Cancer recurrence was significantly associated with reduced oral function. CONCLUSIONS: Oral function in patients with cancer is influenced by various other factors. However, the deep inferior epigastric artery perforator flap may be suitable for tongue reconstruction because of the minimal postoperative changes in flap volume, easy adjustment of flap thickness, elevation of multiple flaps, and minimal complications at the donor site.

Pre-expanded thin DIEP free flap in pediatric upper extremity reconstruction for burn sequelae: A case report.

Deep burns sequelae involving the upper limb are challenging even for experienced surgeons, mainly because local reconstructive options and donor sites are often compromised. The use of free flaps for this type of reconstruction remains difficult due to the small recipient vessel diameter and tendency to vasospasm. Moreover, pediatric cases bring the challenge to another level. We present the case of a 13-year-old girl presenting major retractile sequelae of the upper left limb, including complete wrist immobilization combining wrist hyper-extension, ulnar deviation deformity, and a ulno-carpal dislocation. She was referred to our department where a two-stage reconstruction was performed using a pre-expanded free deep inferior epigastric artery perforator (DIEP) flap. The first surgery consisted of placing two kidney-shaped expanders in a subfascial plane in the hypogastric region. Four months later, after a bi-weekly expansion, an excision of the scar tissue, and the DIEP flap transfer were completed. At the 12-month follow-up evaluation, both aesthetic and functional results were satisfactory, with a good contour and regained mobility of the wrist.

Latex-Infused Porcine Abdominal Model: A Novel Microsurgery Simulator for Deep Inferior Epigastric Perforator Dissection.

BACKGROUND: Perforator dissection and flap elevation are routinely performed for microsurgical reconstruction; however, there is a steep learning curve to mastering these technical skills. Though live porcine models have been utilized as a microsurgical training model, there are significant drawbacks that limit their use, including cost, limited ability for repetition, and obstacles associated with animal care. Here we describe the creation of a novel perforator dissection model using latex augmented non-living porcine abdominal walls. We provide anatomic measurements that demonstrate valuable similarities and differences to human anatomy to maximize microsurgical trainee practice. METHODS: Six latex-infused porcine abdomens were dissected based on the deep cranial epigastric artery (DCEA). Dissection was centered over the abdominal wall mid-segment between the second and fourth nipple line. Dissection steps included exposure of lateral and medial row perforators, incision of anterior rectus sheath with perforator dissection, and dissection of DCEA pedicle. DCEA pedicle and perforator measurements were compared with deep inferior epigastric artery (DIEA) data in the literature. RESULTS: An average of seven perforators were consistently identified within each flap. Assembly of the model was performed quickly and allowed for two training sessions per specimen. Porcine abdominal walls demonstrate similar DCEA pedicle (2.6 ± 0.21 mm) and perforator (1.0 ± 0.18 mm) size compared with a human's DIEA (2.7 ± 0.27 mm, 1.1 ± 0.85 mm). CONCLUSION: The latex-infused porcine abdominal model is a novel, realistic simulation for perforator dissection practice for microsurgical trainees. Impact on resident comfort and confidence within a microsurgical training course is forthcoming.

Safety of Drainless Donor Closure in DIEP Flap-Based Breast Reconstruction: A Prospective Analysis Using Ultrasound.

BACKGROUND: Although drainless donor closure with progressive tension suture (PTS) technique has been attempted to further reduce donor morbidity in deep inferior epigastric perforator (DIEP) flap-based breast reconstruction, its clinical safety has not yet been fully elucidated. This study prospectively investigated donor morbidity after DIEP flap elevation and drain-free donor closure. METHODS: A prospective cohort study was performed on 125 patients who underwent DIEP flap-based breast reconstruction and drainless donor closure. Postoperatively, the donor site was evaluated repetitively using ultrasonography. Development of donor complications, including any fluid accumulation and seroma (defined as detection of fluid accumulation after postoperative one month), was prospectively noted, and independent predictors for the adverse events were evaluated. RESULTS: On ultrasound examination conducted within postoperative 2 weeks, 48 patients were detected to have fluid accumulation at the donor site, which were more frequently detected in cases of delayed reconstruction and those with lesser number of PTS conducted. The majority of those events (95.8%) were resolved with one- or two-times ultrasound-guided aspirations. Five patients (4.0%) showed persistent fluid accumulation after postoperative 1 month, which were successfully treated with repetitive aspiration without requiring reoperation. No other abdominal complications developed except for three of delayed wound healing. On multivariable analyses, harvesting larger-sized flap and conducting lesser number of PTS were independent predictors for the development of fluid accumulation. CONCLUSION: The results of this prospective study suggest that drainless donor closure of the DIEP flap with meticulous placement of PTS followed by postoperative ultrasound surveillance appears to be safe and effective.

Reduction in Seroma Rate Following Deep Inferior Epigastric Perforator Flap with Umbilectomy Utilizing Progressive Tension Sutures.

BACKGROUND: Umbilectomy has been implemented in both abdominoplasties and deep inferior epigastric perforator (DIEP) flaps to improve abdominal wound healing and better control the location of the neoumbilicus; however, seroma rates are increased. The objective of this study is to compare the seroma rate following DIEP flap reconstruction with umbilectomy when progressive tension sutures (PTS) are implemented. METHODS: A retrospective chart review was performed to evaluate postoperative seroma rates in patients undergoing DIEP flap breast reconstruction at a single academic institution between January 2015 and September 2022. All procedures were performed by two senior surgeons. Patients were included if their umbilicus was removed intraoperatively. PTS were utilized in all abdominal closures beginning in late February 2022. Demographics, comorbidities, and postoperative complications were evaluated. RESULTS: A total of 241 patients underwent DIEP flap breast reconstruction with intraoperative umbilectomy. Forty-three consecutive patients received PTS. Overall complications were significantly lower in those who received PTS (p = 0.007). There were no abdominal seromas (0%) in patients who received PTS, whereas 14 (7.1%) occurred without PTS. The use of PTS conferred a decreased likelihood of abdominal seroma (5.687× lower risk, p = 0.017). Additionally, wound formation was significantly lower in those who received PTS (p = 0.031). CONCLUSION: The use of PTS in the abdominal closure during DIEP flap reconstruction addresses the previously seen rise in seroma rates when concomitant umbilectomy is performed. Decrease in both donor-site wounds and now seroma rates reaffirm the efficacy of removing the umbilicus to improve patient outcomes.

To Ablate or Not to Ablate: Does Umbilectomy Decrease Donor-Site Complications in DIEP Flap Breast Reconstruction?

BACKGROUND: Improving outcomes for deep inferior epigastric perforator (DIEP) flap breast reconstruction is an evolving area of interest. The aim of this study was to evaluate the effect of umbilectomy in abdominally based breast reconstruction. METHODS: This retrospective study evaluated postoperative outcomes of patients who underwent autologous DIEP flap breast reconstruction at an academic center between January of 2015 and December of 2021 performed by one of two reconstructive surgeons. The primary outcome variable was abdominal donor-site complications. A secondary outcome variable was treatment outcomes for complications. Covariates included demographic information, comorbidities, cancer treatment, and smoking. RESULTS: A total of 408 patients underwent DIEP flap breast reconstruction, with 194 (47.5%) undergoing umbilectomy. Umbilectomy resulted in decreased number of total wounds per patient (0.35 ± 0.795) compared with umbilical preservation (0.75 ± 1.322; P < 0.001), as well as decreased associated risk of any reported wounds (OR, 0.530; P = 0.009). Associations that trended toward significance occurred between umbilectomy and minor wound separation and partial necrosis, with both showing decreased risk. A significant association was noted between umbilectomy and donor-site seroma [χ 2 (1) = 6.348; P = 0.016], showing an increased risk (OR, 5.761). CONCLUSIONS: Umbilectomy should be discussed with patients and considered as a part of DIEP flap breast reconstruction given the reduction in the risk of abdominal donor-site wounds. Although umbilectomy decreases the rate of wounds, it can increase the risk of seroma; therefore, other interventions, such as progressive tension sutures, may be explored to aid in reducing seroma and improving wound healing. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Small flaps in microsurgical breast reconstruction: Selection between the profunda artery perforator and small deep inferior epigastric artery perforator flaps and associated outcomes and complications.

BACKGROUND: The deep inferior epigastric artery perforator (DIEP) flap is widely used in breast reconstruction and the profunda artery perforator (PAP) flap as alternative. However, the difference between the two flaps in smaller breast reconstruction remains lacking, in particular, the donor site complications. In this case series, the results of small breast reconstruction (≤300 g) using PAP or small DIEP flaps were explored. METHODS: Unilateral immediate breast reconstruction using a free PAP flap or small DIEP flap (≤300 g) from 2011 to 2021 were reviewed retrospectively. Excluding patients with delayed reconstruction, 28 patients, including 17 PAP flaps and 11 small DIEP flaps were enrolled. Flap characteristics, breast and donor site complications, and revision surgeries were reviewed. BREAST-Q™ was used for quality-of-life assessment. RESULTS: Compared with a small DIEP flap, a PAP flap was narrow (7.5 ± 1.1 vs. 10.6 ± 0.7 cm, p < .001), short (20.0 ± 2.6 vs. 25.5 ± 1.8 cm, p < .001) and had a shorter pedicle (5.9 ± 1.6 vs. 9.1 ± 1.0 cm, p < .001). There were no significant differences in acute and late complications of wound healing and fat necrosis, but the average number of revisions in the PAP group was significantly higher (1.9 ± 1.3 vs. 0.8 ± 1.4, p = .041). Patient-reported outcomes using BREAST-Q™ displayed no significant difference between the two groups. CONCLUSION: The outcomes of PAP and small DIEP flaps at the breasts and donor sites are satisfactory, despite that a higher tendency of donor site complications in PAP flap and more aesthetic refinement required in the PAP group. The overall outcomes are acceptable.

Preoperative Imaging Mapping of DIEP Perforators and Intraoperative Selection: Does It Correlate?

BACKGROUND: Preoperative imaging prior to deep inferior epigastric perforator (DIEP) flap harvest is a common practice to locate perforators and identify aberrant anatomy. METHODS: We report a retrospective review of 320 consecutive patients who underwent preoperative computed tomographic angiography (CTA) or magnetic resonance angiography prior to DIEP flap breast reconstruction. The locations relative to the umbilicus of preoperatively identified perforators were compared with the selected intraoperative perforators. The diameter of all intraoperative perforators was also measured. RESULTS: Across the 320 patient, 1,833 potentially suitable perforators were identified on preoperative imaging. A total of 564 of the 795 perforators selected intraoperatively for DIEP flap harvest were within 2 cm of a predicted perforator, for a rate of 70.1%. The size of the perforator was unrelated to the detection rate. CONCLUSION: We were able to demonstrate a sensitivity of 70% of clinically selected DIEP perforators identified on preoperative imaging in this large series. This contrasts with the nearly 100% predictive value reported by others. Continued reporting of findings and methods of measuring are needed to improve the practical efficacy of CTA and raise awareness about the limitations of CTA, despite its well-documented usefulness.

Intra-abdominal pressure increases peri-operatively in patients undergoing deep inferior epigastric perforator flap reconstruction: A prospective study linking high intra-abdominal pressure to non-fatal lung embolism within one patient.

BACKGROUND: The deep inferior epigastric perforator (DIEP) flap is the gold standard for autologous breast reconstruction. The procedure and peri-operative period are associated with the risk of severe post-operative complications, like venous thromboembolic events (VTE) and lung embolism. Whether the intra-abdominal pressure (IAP) increases after the closure of the abdominal defect, thereby potentially affecting the venous backflow and the risk of VTE, is currently not known. AIM: The primary aim is to test if the closure of the abdominal donor site increases the IAP in women undergoing secondary DIEP flap breast reconstruction. MATERIALS AND METHOD: By using a Unometer, we measured the intravesical pressure as a surrogate marker for the IAP, at baseline, immediately after, and 24 h after abdominal skin closure, for 13 patients. RESULTS: The mean IAP increased from 6.1 mmHg (95% CI 4.6-7.7) at baseline to 9.0 mmHg (95% CI 8.0-10.0) immediately after skin closure [mean diff. 2.9 (95% CI 1.0-4.8) (p = 0.007)] and further up to 11.7 mmHg (95% CI 9.0-14.5) 24 h after closure [mean diff. 5.3 (95% CI 1.4-9.1) (p = 0.012)]. We found that IAP varies among the patients, regardless of the tightness of abdominal closure or rectus plication (n = 3). Immediately after closure, none of the isolated patients showed abnormal levels of IAP (>12 mmHg), while eight out of 12 isolated patients (67%) showed IAP levels above the normal range after 24 h. One patient developed a non-fatal lung embolism. CONCLUSION: The mean IAP increases significantly over the post-operative period after DIEP flap reconstruction, although abnormal IAP values are only seen 24 h after the closure of the skin.

[Cytosteatonecrosis after breast reconstruction by fat flap with or without ischemic preconditioning]. / Cytostéatonécrose après reconstruction mammaire par lambeau graisseux avec ou sans préconditionnement ischémique.

INTRODUCTION: Cytosteatonecrosis (CTN) is a frequent postoperative complication after breast autologous reconstruction using DIEP (deep inferior epigastric perforator) flap. CTN radiological diagnostic reveals different types of lesions, as nodes or extended fat necrosis, which become in some cases infected, or pass for tumor recurrence after breast cancer treatment. CTN is caused by intraoperative ischemia of the flap, and no current method can prevent postoperative CTN development after DIEP breast reconstruction. Mechanical ischemic preconditioning, consisting in intraoperative briefs consecutive cycles of ischemia reperfusion using vascular clamp upon the graft pedicle, is used in transplantation surgery. This procedure improves the graft tolerance towards ischemic surgical lesions. The aim of this retrospective observational study was to assess PCIM effects on CTN development after DIEP surgery, comparing CTN occurrence after breast reconstruction using DIEP flap with or without intraoperative PCIM. MATERIAL AND METHODS: All patients breats reconstructed using DIEP flap between novembre 2020 and may 2022, presenting 6 months postoperative breast echography were retrospectively included. Primary outcome was the ultrasonic existence of CTN, according to the Wagner classification. Clinical data, postoperative outcomes such as infection, hematoma or surgical revision, and length of stay in hospital were also recorded. RESULTS: Twenty nine patients among which 8 PCIM were included. CTN occurrence rate after PCIM (25%) was quite lower than CTN rate without PCIM (71,4%), although the difference was not significant (P=0,088). Other postoperative complications rates were not significantly different with or without PCIM. CONCLUSION: PCIM seems to improve CTN occurrence after DIEP breast reconstruction, improving fat flap tolerance to ischemic perioperative lesions. Those preliminary results need to be confirmed with clinical prospective study.

Bilateral gluteal reconstruction with deep inferior epigastric perforator flaps and saphenofemoral arteriovenous loops.

The use of liquid silicone injections for soft tissue augmentation harbors numerous risks and is not approved by the FDA. Still, such injections are frequently performed by unlicensed providers, often in the gluteal region, and can lead to infection, soft-tissue breakdown, scarring, and disfigurement. The purpose of this case report was to demonstrate the use of immediate, abdominally based free flaps for reconstruction in a patient with bilateral total gluteal defects and limited inflow options in the setting of remote silicone injections. The patient is a 45-year-old female who developed chronically infected injected silicone in the bilateral buttocks leading to draining abscesses and soft tissue breakdown. The patient required radical debridement and excision of the bilateral buttocks to remove all foreign material. After intermediate skin grafting of the residual wounds, the patient then was deemed a candidate for bilateral free flap reconstruction of the buttocks. On exploration of the bilateral defects, both 20 cm × 10 cm in size, the gluteal vessels were non-usable, and preoperative CTA additionally had revealed no suitable posteriorly based perforators. Therefore, bilateral arteriovenous (AV) loops, measuring 30 cm in length, were then constructed utilizing the greater saphenous veins anastomosed to the femoral arteries which were then tunneled to the defect. The soft tissue defects were concurrently reconstructed with bilateral deep inferior epigastric perforator (DIEP) flaps measuring 16 cm × 12 cm. The postoperative course was complicated by small seromas in each groin requiring drain placement by interventional radiology on postoperative day 16. Otherwise, the patient's buttocks healed well, and functionally, the patient had regained the ability to sit and was satisfied with the aesthetic appearance of the reconstruction as of last follow-up at 10 months. Abdominally based free flap reconstruction with AV loops, in this case, provided for successful reconstruction of otherwise challenging soft-tissue defects with limited inflow options.

Operative Time Predicts Long-Term Abdominal Morbidity and Complication Requiring Treatment after DIEP Flap Breast Reconstruction.

BACKGROUND: The relationship between skin-to-skin operative time and long-term complications, as well as complications requiring treatment, after deep inferior epigastric perforator (DIEP) flap breast reconstructions has not been thoroughly investigated. The study objective was to evaluate if operative time would independently prognosticate the type and number of treated complications, as well as long-term abdominal morbidity. METHODS: Patients who underwent bilateral DIEP flaps from 2010 to 2021 by two senior surgeons with standardized surgical and postoperative protocols were retrospectively reviewed. Inclusion required at least 1 year of postoperative follow-up. Extensive multivariable regression analyses were utilized to adjust for potential confounders, including measures of intraoperative complexity. RESULTS: Three hundred thirty-five patients were entered into multivariable analyses. After risk adjustment, there was a significant increase in the risk of all treated complications per hour. Each hour of operation increased risk of complications requiring extended hospital stay for treatment by 25%, flap-site complications requiring readmission treatment by 24%, and flap-site complications requiring extended hospital stay for treatment by 26% (all p < 0.0001). Long-term abdominal morbidity (abdominal bulge) increased by 25% per hour of operative time (p < 0.0001). The number of complications requiring treatment, abdominal donor-site complications, and complications requiring extended hospital stay for treatment had statistically significant linear relationships with the duration of surgery (all p < 0.05). CONCLUSION: Operative time predicts long-term abdominal morbidity and complications requiring treatment, especially impacting the odds of developing abdominal bulges and complications requiring extended hospital stay for treatment or readmission treatment. This study emphasizes the importance of reducing operative time to improve DIEP flap breast reconstruction outcomes.