Diametric Comparison between the Thoracodorsal Vessel and Deep Inferior Epigastric Vessel in Breast Reconstruction.
ABSTRACT: Background:In microvascular anastomosis, size discrepancy is common and can increase thrombotic complications. If size differences can be predicted, then vessels of the appropriate size can be selected. This study documented the difference in diameter between the thoracodorsal (TD) vessel and deep inferior epigastric perforator (DIEP) pedicle in each patient who underwent breast reconstruction using free tissue transfer. Patients and Methods. This retrospective study included 32 anastomoses (27 breasts including five cases of supercharged anastomosis) of breast reconstruction with the free DIEP flap and TD recipient between August 2018 and June 2019. In the microscopic view, the caliber of the TD vessel, the largest branch to the serratus anterior muscle, the descending branch, the largest and the second largest branches to the latissimus dorsi muscle, and the DIEP pedicle were measured. Results:The diameter of the deep inferior epigastric artery was similar to that of the descending branch, and their anastomosing rate was 56.3%. The diameter of the deep inferior epigastric vein was similar to the branch to the serratus anterior muscle and the descending branch, and their anastomosing rates were 29.3% and 29.3%, respectively. All flaps were survived; however, in one case, a reoperation was needed to remove the hematoma, in which case fat necrosis occurred as the only complication. Conclusion:TD branches of similar size to the DIEP pedicle were prioritized in anastomosis. The descending branch and the branch to the serratus anterior muscle are expected to be good candidates as recipients in breast reconstruction with DIEP free flap. Moreover, supercharged anastomosis of DIEP pedicles can be achieved within TD branches.
Project description:Although the success rate of deep inferior epigastric perforator (DIEP) flaps has increased, late flap failures still occur and have a low salvage rate. The present article describes a case of salvage of a case of late flap failure using the pedicle vein as a vein graft source. A 50-year-old woman underwent a bilateral DIEP free flap procedure. On postoperative day 6, she experienced flap compromise and underwent emergency flap revision. In the flap revision, flap venous drainage and the superficial inferior epigastric vein were completely obstructed. A Fogarty catheter was used to remove a thrombus from the completely obstructed pedicle vein, and this pedicle vein was used as a graft source and was ligated in retrograde fashion to the flap vein stump. After injection of urokinase into the arterial branch, venous flow to the flap was restored. At a 6-month follow-up visit in the outpatient clinic, only partial fat necrosis at the flap was noted. By dissecting various perforators in the initial operation, decisions regarding immediate revision can be made with more confidence. Additionally, the combined procedures performed in this case may be helpful even for practitioners treating cases of late flap compromise.
Project description:Autologous breast reconstruction has become a standard option during the recovery of breast cancer survivors. Although pedicle damage is a rare complication of this procedure, extensive torsion or tension can lead to partial or total flap failure. We report a case of partial flap salvage after accidental transection of the pedicled blood supply within the intramuscular course of a latissimus dorsi musculocutaneous flap. This salvage technique involved microvascular anastomosis between the remaining vasculature of the latissimus dorsi pedicle and the serratus branch of the thoracodorsal artery and vein.
Project description:The deep inferior epigastric perforator (DIEP) flap has become the free flap of choice for autologous breast reconstruction. However, anastomoses of DIEP pedicles to internal mammary vessels in the chest wall are difficult due to restricted access and the depth of the vessels. Successful performance of such demanding procedures necessitates advanced requirements for microsurgical training models. The current chicken thigh model has been used to acquire microsurgical skills, allowing early learning curve trainees to practice repeatedly in inconsequential environments. Despite the increasing use of this model for training purposes, the resemblance to a clinical environment is tenuous. Such models should include anastomosis practice within the depth where the recipient vessels are located. To address this, we developed a three-dimensional (3D) printed chest wall as an addition to the current chicken thigh model, which reliably mimics the complexity of the anastomosis performed during DIEP breast reconstruction. This form of rapid prototyping facilitates a newfound ability for early learning curve trainees to exercise end-to-end anastomoses on vessels located with variable depths. Our enhancement of the current chicken thigh model is simple, cost-effective and offers a significantly more realistic resemblance to a clinical situation.
Project description:: The deep inferior epigastric perforator (DIEP) flap is becoming the gold standard for breast reconstruction using autologous tissue. If there are scars in the abdomen from previous surgery, it is necessary to judge the indication for using this flap carefully. Particularly in cases with vertical midline scars, the blood flow supply to the zone II can be compromised. Even when patients have a median abdominal scar, it has been reported that the blood flow can extend beyond the scar and reach several centimeters to about half of zone II. We performed breast reconstruction using DIEP flaps for 2 patients with vertical midline scars in the lower abdomen. Indocyanine green angiography was conducted intraoperatively to confirm the vascular territory with a single pedicle before cutting off the flap. One patient showed fluorescence contrast on the contralateral side across the midline scar. However, the fluorescence contrast was absent across the midline scar in the other patient. Based on this result, we investigated the possible vascular territory of a single pedicled DIEP flap in patients with vertical midline abdominal scars. We suggest that successful blood supply to zone II of a single-pedicled DIEP flap in a patient with a vertical midline abdominal scar is related to the location of the perforator and the property of the tissue in the midline near the perforator. However, because it is difficult to predict the vascular territory of a single pedicle before surgery, intraoperative evaluation using such techniques such as indocyanine green fluorescence imaging is important.
Project description:<h4>Background</h4>We developed a novel pedicled DIEP flap model in rat to explore the possible remedy for the distal necrosis of the flap.<h4>Methods</h4>A deep inferior epigastric perforator (DIEP) flap, based on the second right cranial perforator (P2) as the main pedicle, was elevated in 48 Sprague-Dawley rats. The rats were randomized into 4 groups: group I, the left P2 remaining intact as supercharging; group II, the left P2 artery alone kept as supercharging; group III, the left P2 vein alone kept as supercharging; group IV, no supercharging. Transcutaneous oxygen pressure (TcPO2) and transcutaneous carbon dioxide pressure (TcPCO2) were measured immediately after flap elevation, protein level of Hif-1a was measured 48 hours later, and flap survival was assessed 7 days postoperatively.<h4>Results</h4>Blockade of artery led to significantly lower TcPO2, higher TcPCO2, and higher expression level of Hif-1a in the distal side of the flap in group III and group IV, than those of group I and group II. At 7 days post surgery, significantly lower flap survival rates were observed in group III (81.9 ± 5.7%) and group IV (78.4 ± 6.5%), compared to observed in group I (97.2 ± 3.0%) and group II (94.2 ± 6.2%).<h4>Conclusions</h4>It might be arterial insufficiency, not venous congestion, which mainly caused the distal necrosis of the DIEP flap in rat. Arterial instead of venous supercharging might be a more effective procedure that improves circulation to zone IV of the flap.
Project description:<h4>Background</h4>The maximum weight of tissue that a single perforator can perfuse remains an important question in reconstructive microsurgery. An empirically based equation, known as the flap viability index (FVI), has been established to determine what weight of tissue will survive on one or more perforators. The equation is FVI = Sum d(n)^4/W, where d is the internal diameter of each perforator and W is the final weight of the flap. It has been shown that if FVI exceeds 10, total flap survival is likely, but if under 10, partial flap necrosis is probable. The aim of this study was to measure absolute flow rates in deep inferior epigastric perforator (DIEP) flap pedicles and assess correlation with the determinants of the FVI, perforator diameter and flap weight.<h4>Methods</h4>Color Doppler ultrasound was used to quantify arterial flow in 10 consecutive DIEP flap pedicles 24 hours after anastomosis.<h4>Results</h4>In single-perforator DIEP flaps, flow rate was highly correlated with perforator diameter (r = 0.82, P = 0.01). Mean arterial flow rate was significantly reduced in DIEP flaps with 2 or more perforators (6 vs 38 cm(3)/min; P < 0.05).<h4>Conclusions</h4>This study confirms that perforator size is a critical factor in optimizing blood flow in perforator-based free tissue transfer. Further research is required to understand the flow dynamics of perforator flaps based on multiple perforators. However, surgeons should be cognizant that a single large perforator may have substantially higher flow rates than multiple small perforators. Routine FVI calculation is recommended to ensure complete flap survival.
Project description:<h4>Background</h4>Even with patent deep inferior epigastric vein anastomoses, venous congestion can occur during free transverse rectus abdominis musculocutaneous (TRAM) or deep inferior epigastric artery perforator (DIEP) flap surgery and lead to flap compromise if not recognized and managed.<h4>Objectives</h4>To identify the incidence of intraoperative venous congestion and describe the best available prevention and treatment methods.<h4>Methods</h4>Systematic electronic searches of the PubMed database including Medline were performed to identify studies published until 2014. The following keywords were used: "DIEP" or "free TRAM" and "venous insufficiency" or "venous congestion". Supplemental searches were conducted to identify referenced studies. Statistical analysis using the ?(2) test was performed.<h4>Results</h4>Nine studies representing 4747 free abdominal flaps cases were included and demonstrated an overall incidence of intraoperative venous congestion of 2.8%. The incidence in DIEP flaps (3.3%) was significantly higher than that in the free TRAM flaps (1.0%). All nine articles reported using the superficial inferior epigastric vein to treat venous insufficiency.<h4>Conclusion</h4>The risk for developing intraoperative venous congestion following free abdominal flap breast reconstruction is influenced by inadequate perforator selection and persistent dominance in the superficial venous system. The solution is establishing another venous draining route using the superficial inferior epigastric vein.
Project description:Background: Breast cancer is the most common malignancy in women. The interdisciplinary treatment is based on the histological tumor type, the TNM classification, and the patient's wishes. Following tumor resection and (neo-) adjuvant therapy strategies, breast reconstruction represents the final step in the individual interdisciplinary treatment plan. Although manifold flaps have been described, abdominal free flaps, such as the deep inferior epigastric artery perforator (DIEP) or the muscle-sparing transverse rectus abdominis myocutaneous (ms-TRAM) flap, are the current gold standard for autologous breast reconstruction. This retrospective study focuses on the safety of autologous breast reconstruction upon mastectomy using abdominal free flaps. Methods: From April 2012 until December 2018, 193 women received 217 abdominal free flaps for autologous breast reconstruction at the University Hospital of Erlangen. For perforator mapping, we performed computed tomography angiography (CTA). Venous anastomosis was standardized using a ring pin coupler system, and flap perfusion was assessed with fluorescence angiography. A retrospective analysis was performed based on medical records, the surgery report, and follow-up of outpatient course. Results: In most cases, autologous breast reconstruction was performed as a secondary reconstructive procedure after mastectomy and radiotherapy. In total, 132 ms1-TRAM, 23 ms2-TRAM, and 62 DIEP flaps were performed with 21 major complications (10%) during hospital stay including five free flap losses (2.3%). In all cases of free flap loss, we found an arterial thrombosis as the main cause. In 24 patients a bilateral breast reconstruction was performed without free flap loss. The majority of free flaps (96.7%) did not need additional supercharging or turbocharging to improve venous outflow. Median venous coupler size was 2.5 mm (range, 1.5-3.5 mm). Conclusion: Using CTA, intraoperative fluorescence angiography, titanized hernia meshes for rectus sheath reconstruction, and venous coupler systems, autologous breast reconstruction with DIEP or ms-TRAM free flaps is a safe and standardized procedure in high-volume microsurgery centers.
Project description:The deep inferior epigastric perforator (DIEP) adipocutaneous flap is a versatile flap that has been most popularly used in breast reconstruction. However, it has been applied to many other anatomic areas and circumstances that require free-tissue transfer. We present a case report of the use of the DIEP flap for the reconstruction of severe craniomaxillofacial deformity complicated by indolent infection in a gentleman with infected hardware and methyl methacrylate overlay used in previous repair of traumatic injuries suffered from a motor vehicle collision. The reconstruction was done in a staged, two-step fashion that allowed for adequate infection eradication and treatment using a bilateral, bipedicled DIEP flap for tissue coverage and intravenous antibiotics before the delayed insertion of a polyetheretherketone cranioplasty for reconstruction of the cranial defect.
Project description:BACKGROUND:The authors investigated aesthetic outcome and patient satisfaction in women who have undergone deep inferior epigastric artery perforator (DIEP) flap reconstruction in the setting of postmastectomy radiotherapy. Patients who underwent DIEP flap reconstruction without postmastectomy radiotherapy were the control group. METHODS:Participants who had undergone DIEP flap reconstruction between September 1, 2009, and September 1, 2014, were recruited, answered the BREAST-Q, and underwent three-dimensional surface-imaging. A panel assessed the aesthetic outcome by reviewing these images. RESULTS:One hundred sixty-seven women participated. Eighty women (48 percent) underwent immediate DIEP flap reconstruction and no postmastectomy radiotherapy; 28 (17 percent) underwent immediate DIEP flap reconstruction with postmastectomy radiotherapy; 38 (23 percent) underwent simple mastectomy, postmastectomy radiotherapy, and DIEP flap reconstruction; and 21 (13 percent) underwent mastectomy with temporizing implant, postmastectomy radiotherapy, and DIEP flap reconstruction. Median satisfaction scores were significantly different among the groups (p < 0.05). Post hoc comparison demonstrated that women who had an immediate DIEP flap reconstruction were significantly less satisfied if they had postmastectomy radiotherapy. In women requiring radiotherapy, those undergoing delayed reconstruction after a simple mastectomy were most satisfied, but there was no significant difference between the immediate DIEP flap and temporizing implant groups. Median panel scores differed among groups, being significantly higher if the immediate reconstruction was not subjected to radiotherapy. There was no significant difference in panel assessment among the three groups of women who had received radiotherapy. CONCLUSIONS:Patients who avoid having their immediate DIEP flap reconstruction irradiated are more satisfied and have better aesthetic outcome than those who undergo postmastectomy radiotherapy. In women requiring radiotherapy and who wish to have an immediate or "delayed-immediate" reconstruction, there were no significant differences in panel or patient satisfaction. Therefore, immediate DIEP flap reconstruction or mastectomy with temporizing implant then DIEP flap surgery are acceptable treatment pathways in the context of post-mastectomy radiotherapy.