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PURPOSE: Autologous breast reconstruction improves patient satisfaction and quality of life after mastectomy. In Germany, free flap surgery and implant-based reconstruction is usually separate between reconstructive surgery and gynecology. Cooperation between the specialist disciplines and implementation of microsurgery into breast surgeon training could enhance surgical treatment for breast cancer patients. This evaluation is intended to demonstrate the learning progress within a microsurgical training program and the complication rate in relation to microsurgical experience. METHODS: At the breast cancer center at Klinikum rechts der Isar, TU Munich, a three-stage training program for autologous breast reconstruction and microsurgery for gynecological breast surgeons was developed. Between 2019 and 2022, 74 women received autologous free flap breast reconstruction by a consistent team consisting of a gynecological surgeon in training and an expert microsurgeon. Peri- and postoperative data were collected to analyze the feasibility and safety of a microsurgical training in gynecology. RESULTS: Within the training, operative steps of free autologous breast reconstruction were increasingly taken over by the gynecological surgeon in training. The analysis showed a decrease in operating times with consistently low complication rates during the training. CONCLUSION: This study demonstrated that a training in free autologous breast reconstruction for gynecological surgeons is safely feasible through close cooperation between gynecological and reconstructive surgery.
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Neoplasias da Mama , Ginecologia , Mamoplastia , Cirurgiões , Humanos , Feminino , Neoplasias da Mama/cirurgia , Mastectomia , Qualidade de Vida , Currículo , Microcirurgia , Estudos RetrospectivosRESUMO
Introduction Breast reconstruction has become integral part of breast cancer treatment. Deep inferior epigastric perforator (DIEP)-based flap is considered the gold standard in autologous breast reconstruction. Aims and Objectives The aim of this study was to evaluate the patient satisfaction and the incidence of complications in DIEP flaps in an Indian setup for breast reconstruction. Materials and Methods This is a prospective, nonrandomized study at a single institute-Manipal Hospitals, Old Airport Road, Bangalore. Eligible patients were women aged between 28 and 60 years with primary breast cancer requiring mastectomy and radiotherapy, who consented for DIEP flap reconstruction. Results The study includes subjects who had autologous breast reconstruction after mastectomy with DIEP flap between January 2019 and August 2021 that included 31 patients with a minimum follow-up of 2 years. Four flaps were turbocharged and 17 flaps were superdrained primarily. The average operative time for the whole procedure by adopting a two-team approach is 353.8 ± 43.793 minutes. About 94.1% patients had excellent aesthetic score results. Six patients developed mastectomy flap necrosis, one had fat necrosis that was managed conservatively, whereas one patient had donor site re-exploration for hematoma. We had no DIEP flap necrosis, seroma, flap site hematoma, or flap failure. Physical well-being module of Breast-Q indicated an average of 83 points, psychosocial well-being module indicated 80 points, whereas sexual scores reverted an average of 77 points. Among satisfaction module, aesthetic outcomes for breast showed an average of 94 points, whereas the donor site had 96 points. Satisfaction with information, surgeon, medical staff each gained more than 87 points. Conclusion Breast reconstruction with DIEP flap yields good aesthetic outcomes and quality of life in Indian population. The incidence of fat necrosis, flap and donor site complications is less over time and will enhance the patient satisfaction score further.
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BACKGROUND: This study investigated the outcomes of nipple-sparing mastectomy (NSM) with a deep inferior epigastric perforator (DIEP) flap using delayed primary retention suture (DPRS) to achieve superior breast esthetics. METHODS: Between December 2010 and March 2021, patients who underwent NSM with DIEP flap were inset with or without a skin paddle (using DPRS) as Group A or B, respectively. Demographics, operative findings, complications, BREAST-Q questionnaire, and Manchester scar scale were compared between two groups. RESULTS: Twelve patients underwent 12 unilateral reconstructions in Group A, while 12 patients underwent 13 DIEP flaps in Group B. There was no significant difference in demographics, ischemia time, flap-used weight and percentage, complications of hematoma, infection, re-exploration, partial flap loss, and total flap loss (All p > 0.05, respectively). At a mean 9 months of follow-up, the Breast-Q "Satisfaction with surgeon" domain was significant in Group B (p = 0.04). At a mean 12 months of follow-up, the overall Manchester scar scale of 10.3 in Group B was statistically superior to 12.6 in Group A (p = 0.04). CONCLUSIONS: The NSM with a DIEP flap using DPRS is a reliable and straightforward technique. It can provide greater cosmesis of the reconstructed breast mound in a single-stage procedure.
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Neoplasias da Mama , Mamoplastia , Retalho Perfurante , Neoplasias da Mama/cirurgia , Cicatriz/cirurgia , Artérias Epigástricas/cirurgia , Feminino , Humanos , Mamoplastia/métodos , Mastectomia/métodos , Mamilos/cirurgia , Satisfação do Paciente , Retalho Perfurante/cirurgia , Estudos Retrospectivos , SuturasRESUMO
Background and Objectives: When a lymphatic-rich area is severely damaged, either after trauma or a surgical procedure, both soft tissue defect reconstruction and lymphatic drainage restoration are necessary. In this setting, we aim to show the potential of the lymphatic flow-through flap (LyFT) concept, which might be an attractive new solution to reduce postoperative lymphatic complications. Materials and Methods: Between 2018 and 2021, 12 patients presenting a soft tissue defect involving damage to the lymphatic drainage pathway received a lymphatic flow-through flap for volume and lymphatic drainage restoration. Different flaps were employed: 3 pedicled superficial circumflex iliac artery perforator (SCIP) flaps, 2 free SCIP flaps, 3 pedicled deep inferior epigastric perforator (DIEP) flaps, 2 pedicled vertical posteromedial thigh (vPMT) flaps, and 2 pedicled anterolateral thigh (ALT) flaps. A range of 1 to 3 lymphovenous anastomosis (LVA) with flap's veins was performed (mean 1.9). For a better dead space obliteration, an additional vastus lateralis muscle flap was performed in one case. Indocyanine green (ICG) lymphography was used in all cases to identify the lymphatic pathway, make the preoperative markings, and check the patency of the anastomoses. Results: In all cases, the reconstructive results were satisfactory from both the functional and aesthetic points of view. No secondary surgeries were required, and only one minor complication was encountered: an infected seroma that was managed conservatively. The mean follow-up was 9.9 months (range 6-14 months). Conclusions: Lymphatic flow-through flaps seem to effectively reduce the risk of lymphatic complications after the reconstruction of soft tissue defects with a compromised lymph pathway. This is a versatile solution that might be used in different body regions resorting to different flap types.
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Vasos Linfáticos , Retalho Perfurante , Procedimentos de Cirurgia Plástica , Humanos , Artéria Ilíaca/cirurgia , Vasos Linfáticos/cirurgia , Retalho Perfurante/irrigação sanguínea , Retalho Perfurante/cirurgia , Complicações Pós-Operatórias/cirurgia , Procedimentos de Cirurgia Plástica/métodos , Coxa da Perna/cirurgiaRESUMO
BACKGROUND: Deep inferior epigastric perforator (DIEP) flap reconstruction is the gold standard reconstructive technique for women undergoing breast cancer surgery. A preoperative computed tomography angiography (CTA)-dedicated protocol and 3D reconstructions are mandatory for correct surgical planning. PURPOSE: To evaluate the diagnostic performance of a new preoperative CTA protocol and a new reconstruction method in the assessment of DIEP technique. MATERIAL AND METHODS: A total of 263 women (median age 49 years, age range 26-73 years) underwent preoperative CTA examination before DIEP flap breast reconstruction. A CTA-dedicated protocol followed by 3D-reconstructions were performed. Identification, branching pattern, and caliber at origin were assessed for each perforator. Intraoperative findings were the standard of reference. The sensitivity, positive predictive value, and diagnostic accuracy of the preoperative CTA protocol were calculated. RESULTS: In 255/263 (97%) patients, the dominant perforators assessed by CTA resulted adequate for surgical reconstruction. In 260/263 (99%) cases, the imaging localization of the dominant perforators corresponded with those seen intraoperatively (mean errors ≤1 cm). The preoperative CTA imaging sensitivity, positive predictive value, and diagnostic accuracy in determining the localization of perforators were 99% (95% CI 98-100), 100% and 99% (95% CI 98-100), respectively. No statistically significant differences were found between the CTA findings and the surgical findings for the assessment of branching pattern and caliber of the dominant perforators (P < 0.001). CONCLUSION: The present protocol has demonstrated high accuracy in the CTA imaging assessment of the perforators before DIEP flap reconstruction with high reproducibility between CT and surgical findings.
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Neoplasias da Mama/cirurgia , Angiografia por Tomografia Computadorizada/métodos , Artérias Epigástricas/diagnóstico por imagem , Mamoplastia/métodos , Retalho Perfurante/irrigação sanguínea , Cuidados Pré-Operatórios/métodos , Parede Abdominal/irrigação sanguínea , Adulto , Idoso , Mama/diagnóstico por imagem , Mama/cirurgia , Feminino , Humanos , Imageamento Tridimensional/métodos , Pessoa de Meia-Idade , Estudos Prospectivos , Reprodutibilidade dos TestesRESUMO
Despite being especially used in its solid form, silicone is still injected as a liquid filler for breast contouring in many countries. Here, we present a rare case of a woman with silicone pneumonitis and extended breast scarring after breast silicone injection. Because of evidence of a restrictive syndrome due to the thoracic extensive scarring tissue and the high demand of oxygen therapy, as jointly agreed with the pulmonologists, we decided to perform a surgical asportation of the scarring tissue and covering with microsurgical flap. We chose the deep inferior epigastric perforator flap mainly because of the large amount of skin that is possible to use, the good skin texture matching, and the possibility of double team working without changing patient's position.
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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.
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Angiografia por Tomografia Computadorizada , Artérias Epigástricas/anatomia & histologia , Artéria Ilíaca/anatomia & histologia , Mamoplastia/métodos , Reto do Abdome/irrigação sanguínea , Feminino , Humanos , Microcirurgia/métodosRESUMO
BACKGROUND AND OBJECTIVES: The deep inferior epigastric perforator (DIEP) flap may be associated with less long-term donor-site morbidity compared with free muscle-sparing transverse rectus abdominis myocutaneous flap (MS-TRAM) flap. However, DIEP flaps may have longer operative time and higher rates of acute postoperative complications. We performed a cost-effectiveness analysis (CEA) that compared the long-term costs and patient-reported outcomes between the two flaps. METHODS: A retrospective cohort of women who received free MS-TRAM or DIEP flap reconstruction between January 2008 and December 2012, with a minimum of 2-year follow-up, were recruited. Cost data of the primary reconstruction and any subsequent hospitalization due to complications from the reconstruction within 2 years were obtained. Each patient received a BREAST-Q questionnaire at 2 years post-reconstruction. RESULTS: In total, 227 patients (180 DIEP, 47 free MS-TRAM) were included. DIEP patients had significantly fewer abdominal hernia (P = 0.04). The adjusted-incremental cost-effectiveness ratios found that DIEP flap was more cost-effective to free MS-TRAM flap in the domains of "Physical Well-Being of the Abdomen" and "Satisfaction with Outcome." CONCLUSIONS: DIEP flap is the more cost-effective method of autologous breast reconstruction in the long-term compared with free MS-TRAM flap with respect to patient-reported abdominal well-being and overall satisfaction with the outcome.
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Neoplasias da Mama/economia , Análise Custo-Benefício , Artérias Epigástricas/transplante , Retalhos de Tecido Biológico/transplante , Mamoplastia/economia , Complicações Pós-Operatórias/economia , Reto do Abdome/transplante , Neoplasias da Mama/patologia , Neoplasias da Mama/cirurgia , Feminino , Seguimentos , Retalhos de Tecido Biológico/irrigação sanguínea , Humanos , Pessoa de Meia-Idade , Retalho Perfurante/irrigação sanguínea , Prognóstico , Reto do Abdome/irrigação sanguínea , Estudos RetrospectivosRESUMO
BACKGROUND AND OBJECTIVES: Two staged tissue expander-implant with acellular dermal matrix (TE/I + ADM) and deep inferior epigastric perforator (DIEP) flap are the most common implant and autologous methods of reconstruction in the U.S. Implant-based techniques are disproportionally more popular, partially due to its presumed cost effectiveness. We performed a comprehensive cost analysis to compare TE/I + ADM and DIEP flap. METHODS: A comparative cost analysis of TE/I + ADM and DIEP flap was performed. Medicare reimbursement costs for each procedure and their associated complications were calculated. Pooled probabilities of complications including cellulitis, seroma, skin necrosis, implant removal, flap loss, partial flap loss, and fat necrosis, were calculated using published studies from 2010 to 2016. RESULTS: Average actual cost for successful TE/I + ADM and DIEP flap were $13 304.55 and $10 237.13, respectively. Incorporating pooled complication data from published literature resulted in an increase in cost to $13 963.46 for TE/I + ADM and $12 624.29 for DIEP flap. The expected costs for successful TE/I + ADM and DIEP flap were $9700.35 and $8644.23, which are lower than the actual costs. CONCLUSIONS: DIEP flap breast reconstruction incurs lower costs compared to TE/I + ADM. These costs are lower at baseline and when additional costs from pooled complications are incorporated.
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Derme Acelular/economia , Implantes de Mama/economia , Mamoplastia/economia , Mamoplastia/métodos , Retalho Perfurante/economia , Expansão de Tecido/economia , Implante Mamário/economia , Implante Mamário/métodos , Custos e Análise de Custo , Feminino , Humanos , Mastectomia , Medicare/economia , Transplante de Pele/economia , Estados UnidosRESUMO
BACKGROUND: For some patients seeking autologous breast reconstruction, there may be insufficient abdominal skin and soft tissue to reconstruct an adequately sized breast. Perfusion from a single-pedicle deep inferior epigastric perforator artery flap has a high degree of variability across the midline, and this further limits perfusion. We have found that bipedicle-conjoined abdominal perforator flaps are a novel and reliable technique for reconstruction in these women, and this study examines our experience. MATERIALS AND METHODS: A retrospective review was performed over a 2-y period of bipedicle-conjoined abdominal perforator flaps in 28 patients. For each reconstruction, the pedicle of one flap was anastomosed to the anterograde internal mammary artery vessels and the pedicle of the second flap to a side branch of the primary flap or the retrograde internal mammary vessels. RESULTS: Mean age and body mass index were 50.2 y (standard deviation, 8.0) and 25.9 kg/m(2) (standard deviation, 2.8), respectively. In total, 15 patients (53.6%) received radiation therapy before surgery. There were no flap losses; fat necrosis was found in one flap (3.2%). The large contiguous skin island of the bipedicle-conjoined deep inferior epigastric perforator flaps allowed for extensive replacement of damaged or absent breast skin when necessary. Aesthetically satisfactory results were achieved in all patients. CONCLUSIONS: Bipedicle-conjoined abdominal perforator flaps represent a novel technique in select patients seeking breast reconstruction. The added complexity was safe and reliable in this series of patients. Compared to unipedicle flaps, the increased skin and volume allow greater flexibility to achieve the desired shape and projection.
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Neoplasias da Mama/cirurgia , Artérias Epigástricas/cirurgia , Mamoplastia/métodos , Artéria Torácica Interna/cirurgia , Retalho Perfurante , Adulto , Idoso , Anastomose Cirúrgica , Feminino , Humanos , Mastectomia , Pessoa de Meia-Idade , Retalho Perfurante/irrigação sanguínea , Estudos Retrospectivos , Resultado do TratamentoRESUMO
The skin between the mastectomy scar and the future infra-mammary fold may be managed in different ways in delayed breast reconstruction using a DIEP (deep inferior epigastric perforator). Conserving this skin and positioning the flap skin paddle in the middle of the breast usually highlights skin color disparity because of two visible transition zones. Resection of the entire skin under the scar may be more aesthetic but limits direct closure possibility in case of flap failure. In order to benefit from both aesthetic result and safe surgical method, we propose the abdominal drop flap. The inferior thoracic skin flap is detached from the thoracic wall beyond the future infra-mammary fold, preserved and pushed under the breast.
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Mamoplastia/métodos , Retalhos Cirúrgicos , Feminino , Humanos , Mastectomia , Parede Torácica/cirurgiaRESUMO
PURPOSE: The deep inferior epigastric perforator (DIEP) flap provides excellent results when performed by a trained surgical team. However, the beginning of the procedure is often complicated. To date, few authors have published their initial experiences. This study presents our team's experience using a DIEP flap in breast reconstruction. METHODS: From June 2008 until December 2013, the same leading operator performed 132 consecutive DIEP flaps. Breast reconstructions were immediate (n=18) or delayed (n=114), unilateral (n=110) or bilateral (n=11). The learning curve was assessed using the operating time, ischemic time, postoperative hospital stay, and complications. For statistical comparisons, unilateral reconstructions were divided into five chronologic groups of 22 consecutive DIEP flaps and two chronologic groups of 55 flaps. RESULTS: The average time of surgery was 291 min (range, 185-645) for unilateral breast reconstruction and 513 min (range, 400-790) for bilateral breast reconstruction. The global complication rate was 24.5%. In the unilateral series, the time of surgery decreased progressively from 415 min to 233 min (P=4.8×10(-8)). The mean postoperative hospital stay was reduced from 7.14 days to 6.32 days (P=0.042). The complications and flap failure rates had regular time distributions. Initially, the revision rate reached 50% for the first ten unilateral cases but decreased rapidly and remained steady at 6% for the following cases (P=0.0012). CONCLUSIONS: Our initial experience of DIEP flap breast reconstruction showed a significant improvement of surgical performances exceeding 50 cases, with a critical ten first case period.
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Mamoplastia , Retalho Perfurante , Adulto , Idoso , Feminino , Hospitais Universitários , Humanos , Curva de Aprendizado , Mastectomia , Pessoa de Meia-Idade , Duração da Cirurgia , Reoperação/estatística & dados numéricos , Estudos Retrospectivos , Adulto JovemRESUMO
This study aims to present the case of a female patient with Poland's syndrome and pectus excavatum deformity who underwent breast and chest wall reconstruction with a pre-shaped free deep inferior epigastric perforator flap. A 57-year-old female patient with Poland's syndrome and pectus excavatum presented with a Baker III capsular contracture following a previously performed implant-based right breast reconstruction. After a chest and abdominal CT angiography, she was staged as 2A1 chest wall deformity according to Park's classification and underwent implant removal and capsulectomy, followed by a pre-shaped free abdominal flap transfer, providing both breast reconstruction and chest wall deformity correction in a single stage operation. Post-operative course was uneventful, and the aesthetic result remains highly satisfactory 24 months after surgery. Deep inferior epigastric free flap represents an interesting reconstructive solution when treating Poland's syndrome female patients with chest wall and breast deformities.
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With increasing interest in swift postoperative recovery, there has been a trend toward omitting drains in deep inferior epigastric perforator (DIEP) flap-based breast reconstruction, ideally aiming to avoid drains in the breasts and abdomen. This study evaluated our transition toward total drainless reconstruction, focusing specifically on the safety of omitting drains in the breasts. Patients who underwent breast reconstruction with DIEP flap from 2018 to 2023 were reviewed. They were divided into 3 groups: group A (with drains in the abdomen and breast), group B (drains only in the breast), and group C (total drainless). For group C, routine ultrasound examinations were performed to check for fluid accumulation. Complication profiles were compared among the groups. In total, 294 cases were included, comprising 77 in group A, 112 in group B, and 105 in group C. Chronologically, a gradual increase in the proportion of cases in group C was observed, with the complication rates remaining stable. On comparing the complication profiles of the recipient and donor sites among the 3 groups, no significant differences were found. Breast seroma, persisting 1 month postoperatively, was exclusively detected in 6 (5.7%) cases within group C, all of whom were treated with outpatient clinic-based aspiration. When restricting the analysis to group C, a greater weight of mastectomy specimen and axillary lymph node dissections exhibited an independent association with breast seroma development. Smooth transition to total drainless DIEP breast reconstruction appears safe, without significantly increasing the risks of complication.
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Drenagem , Mamoplastia , Retalho Perfurante , Complicações Pós-Operatórias , Humanos , Mamoplastia/métodos , Mamoplastia/efeitos adversos , Feminino , Pessoa de Meia-Idade , Drenagem/métodos , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/prevenção & controle , Complicações Pós-Operatórias/etiologia , Adulto , Artérias Epigástricas/transplante , Estudos Retrospectivos , Seroma/etiologia , Neoplasias da Mama/cirurgiaRESUMO
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.
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Mamoplastia , Retalho Perfurante , Humanos , Abdome/cirurgia , Mama/cirurgia , Artérias Epigástricas/cirurgia , Mamoplastia/efeitos adversos , Mamoplastia/métodos , Retalho Perfurante/efeitos adversos , Retalho Perfurante/cirurgia , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/cirurgiaRESUMO
BACKGROUND: Now-a-days, deep inferior epigastric perforator (DIEP) flap breast reconstruction is widespread throughout the world. The aesthetical result is very important in breast reconstruction and its improvement is mandatory for plastic surgeons. MATERIALS AND METHODS: The most frequent problems, we have observed in breast reconstruction with DIEP flap are breast asymmetry in terms of volume and shape, the bulkiness of the inferior lateral quadrant of the new breast, the loss of volume of the upper pole and the lack of projection of the inferior pole. We proposed our personal techniques to improve the aesthetical result in DIEP flap breast reconstruction. Our experience consists of more than 220 DIEP flap breast reconstructions. RESULTS: The methods mentioned for improving the aesthetics of the reconstructed breast reported good results in all cases. CONCLUSION: The aim of our work is to describe our personal techniques in order to correct the mentioned problems and improve the final aesthetical outcome in DIEP flap breast reconstruction.
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Background One-stage reconstruction with "thin perforator flaps" has been attempted to salvage limbs and restore function. The deep inferior epigastric perforator (DIEP) flap is a commonly utilized flap in breast reconstruction (BR). The purpose of this study is to present the versatility of DIEP flaps for the reconstruction of large defects of the extremities. Methods Patients with large tissue defects on extremities who were treated with thin DIEP flaps from January 2016 to January 2018 were included. They were minimally followed up for 36 months. We analyzed the etiology and location of the soft tissue defect, flap design, anastomosis type, outcome, and complications. We also considered the technical differences in the DIEP flap between breast and extremity reconstruction. Results Overall, six free DIEP flaps were included in the study. The flap size ranged from 15 × 12 to 30 × 16 cm 2 . All flaps were transversely designed similar to a traditional BR design. Three flaps were elevated with two perforators. Primary closure of the donor site was possible in all cases. Five flaps survived with no complications. However, partial necrosis occurred in one flap. Conclusion A DIEP flap is not the first choice for soft tissue defects, but it should be considered for one-stage reconstruction of large defects when the circulation zone of the DIEP flap is considered. In addition, this flap has many advantages over other flaps such as provision of the largest skin paddle, low donor site morbidity with a concealed scar, versatile supercharging technique, and a long pedicle.
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We report a 60-year-old patient who underwent bilateral mastectomy at different times, followed by immediate autologous reconstruction with different flaps: deep-inferior epigastric-perforator flap on one breast, and fat-augmented latissimus dorsi on the contralateral side. At 20-month follow-up, good symmetry was recorded; patient-reported outcome measurements revealed high satisfaction scores.
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Ulceration of a reconstructed nipple occurred in a woman in her 50s who had undergone mastectomy, axillary lymph node dissection, and deep inferior epigastric artery perforator flap reconstruction for right breast cancer. The implanted cartilage was removed on suspicion of infection and the ulcer was biopsied. Local recurrence was identified on histopathological examination. Local recurrence near a reconstructed nipple can cause ulceration because of the fragility of the reconstructed nipple tissue. If erosion or ulceration develops in the reconstructed nipple relatively long after surgery, pathological examination is warranted.
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Autologous reconstruction techniques for breast reconstruction have significantly evolved in the last few decades in Europe. In the search of reducing the donor site morbidity, surgeons explored the possibilities to preserve the rectus muscle and its function, and a transition to deep inferior epigastric perforator (DIEP) flaps was started in the nineties. Throughout the years, and especially in the last decade, we have increasingly implemented aesthetic refinements for donor site handling in DIEP flap breast reconstruction. In our practice, autologous breast reconstruction provides an opportunity to effectively remodel the donor site, minimising functional morbidity, and maximising aesthetic satisfaction. To achieve this, careful patient selection, pre-operative preparation, meticulous intra-operative dissection, and a clear post-operative protocol are essential. The main goal in autologous breast reconstruction, and its biggest advantage, is to offer the patient a natural look and feel of the reconstructed breast. A second goal is to minimize the number of procedures needed to reach the desired breast shape, size, and volume. In most patients, the number of operations ranges between one and three. The third main goal is to minimize the donor site morbidity, both functionally and aesthetically. Functionally, this implies preserving as much of the rectus abdominis muscle as possible, limiting the fascia incision, preserving the motor branches to the muscle, ensuring an adequate fascial closure, and repairing the rectus diastasis is present. Aesthetically, we aim to have a low position of the scar, an aesthetically pleasing location of the umbilicus, and limited or no lateral skin excess or so called "dogears". In this clinical practice review article, we provide an overview of current autologous reconstruction methods, with a focus on minimising donor site morbidity and enhancing the aesthetic result of the donor site. We discuss key concepts in autologous reconstruction and provide surgical pearls for performing the procedure effectively with optimal reconstructive and aesthetic result.