Bilateral breast reconstruction with DIEP flaps: 4 years’ experience
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Keywords:
DIEP flap
Fat necrosis
Rectus abdominis muscle
Objective To discuss the feasibility and method of immediate breast reconstruction right after modified radical mastectomy in early breast carcinoma patients.Methods Deep inferior epigastric artery perforaton flaps were immediately applied on patients to reconstruct the breast after the skin-sparing mastectomy.The breasts were shaped after the deep inferior epigastric artery and vein were anastomosed to the thoraeodorsal artery and vein.Results In 10 cases of breast reconstruction by DIEP flaps since 2005,there were completely survival in 8 flaps,distal skin necrosis in 1 flap,adiponecrosis in 1 flap.With the follow-up of 9-28 months,the reconstructed breasts were well-shaped and there were no abdominal complication in dnor sites.Ninety percent patients were satisfied with the results from the good to the best level.Conclusion Most patients were satisfied with the results of mastectomy reconstruction.
Key words:
Breast neoplasms; Mammaplasty; Surgical flaps
DIEP flap
Rectus abdominis muscle
Fat necrosis
Inferior epigastric artery
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Deep inferior epigastric perforator (DIEP) flap breast reconstruction is an improved method of autologous tissue breast reconstruction with minimal insult to the abdominal wall. This study summarizes the data collected on 148 consecutive DIEP flaps used for breast reconstruction in 109 patients. Of the patients, 90.7% had immediate breast reconstruction after mastectomy, 6.5% had secondary reconstruction, and 2.8% had bilateral reconstruction after having had a mastectomy and having a new primary cancer diagnosed in the remaining breast. A total of 78.7% patients underwent unilateral reconstruction, 21.3% underwent bilateral reconstruction, and 15.7% needed two flaps to make a single larger breast. There was one flap failure. Incidence of fat necrosis was 6.8% and incidence of incisional hernia was 1.4%. The advantages of a free transverse rectus abdominis musculocutaneous flap breast reconstruction are inherent in DIEP flap breast reconstruction. The increased technical effort for DIEP flap reconstruction is offset by the lesser insult to the abdominal wall with maintenance of the entire rectus abdominis muscle.
DIEP flap
Fat necrosis
Rectus abdominis muscle
Abdominal Hernia
Tissue expansion
Modified Radical Mastectomy
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Background: Breast reconstruction using flaps from the lower abdomen can be compromised by fat necrosis. The muscle-sparing free transverse rectus abdominis musculocutaneous (TRAM), deep inferior epigastric perforator (DIEP), and superficial inferior epigastric artery (SIEA) flaps are techniques that have evolved in an effort to decrease abdominal donor-site morbidity. Each flap in this evolution, however, includes fewer perforating blood vessels. The authors hypothesized that flaps with fewer perforators are less well perfused and therefore more likely to suffer fat necrosis. Methods: The authors prospectively studied the incidence of fat necrosis and number of perforators in 228 consecutive abdominal free flap breast reconstructions. Results: The incidence of fat necrosis was 14, 25, 5, and 19 percent for SIEA flaps and flaps with one to two, three to five, and more than five perforators, respectively. The incidence of fat necrosis was significantly associated with the number of perforators (p = 0.007), smoking (p = 0.02), and inclusion of zone 3 of flaps (p = 0.05). The lowest risk of fat necrosis occurs in flaps with three to five perforators, which are predominantly muscle-sparing TRAM flaps. The risk of fat necrosis is highest in flaps with one or two perforators, which are predominantly DIEP flaps. SIEA flaps, and flaps with poor perforators in which greater than five perforators were included, had an intermediate risk of fat necrosis. Conclusions: The risk of fat necrosis in breasts reconstructed with free muscle-sparing TRAM, DIEP, and SIEA flaps increases as the number of perforators supplying the flap decreases. Breast reconstruction using DIEP and SIEA flaps may decrease abdominal donor-site morbidity compared with muscle-sparing TRAM flap techniques, but these flaps also carry a higher risk of fat necrosis that can compromise the breast reconstruction.
DIEP flap
Fat necrosis
Rectus abdominis muscle
Perforator flaps
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Background Despite the decrease in donor‐site morbidity with the advent of deep inferior epigastric artery perforator (DIEP) flap breast reconstruction, abdominal complications still occur. There have been few studies on donor morbidity considering the ethnic differences in the Asian population, as represented by a lower BMI with less redundant tissue and a tendency for poor scarring. In the present study, the authors investigated the incidence of abdominal complications and their risk factors following DIEP flap breast reconstruction in an Asian population. Patients and methods The authors conducted a retrospective review of DIEP flap based breast reconstructions performed in the past 5 years. Data regarding patient demographics, surgical details, and abdominal complications were collected from our prospectively maintained database and analyzed. Results A total of 217 patients who underwent DIEP flap breast reconstruction were included. There were 51 abdominal complications (23.5%), including 18 delayed wound healing, 17 hypertrophic scarring, 12 seroma formation, and 8 abdominal bulges with no hernias. Secondary procedures were performed for the donor‐site complications in 36 cases. Flap height was a significant risk factor for overall donor‐site morbidity. Harvesting a bipedicle flap was significantly associated with abdominal fat necrosis and hypertrophic scarring. Harvesting a flap based on perforators from both rows was significantly associated with abdominal delayed wound healing and hypertrophic scarring. Conclusions DIEP flap breast reconstruction performed in Asian patients showed acceptable donor‐site morbidity without significant complications. This study suggests that donor‐site morbidity from harvesting a DIEP flap is comparable to that described in Western literatures. © 2015 Wiley Periodicals, Inc. Microsurgery 35:596–602, 2015.
DIEP flap
Seroma
Fat necrosis
Rectus abdominis muscle
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Background Our objective was to compare the complication rates of two common breast reconstruction techniques performed at our hospital and the cost-effectiveness for each test group. Methods All patients who underwent deep inferior epigastric perforator (DIEP) flap and transverse rectus abdominis myocutaneous (TRAM) flap by the same surgeon were selected and matched according to age and mastectomy with or without axillary clearance. Patients from each resultant group were selected, with the patients matched chronologically. The remainder were matched for by co-morbidities. Sixteen patients who underwent immediate breast reconstruction with pedicled TRAM flaps and 16 patients with DIEP flaps from 1999 to 2006 were accrued. The average total hospitalisation cost, length of hospitalisation, and complications in the 2 year duration after surgery for each group were compared. Results Complications arising from both the pedicled TRAM flaps and DIEP flaps included fat necrosis (TRAM, 3/16; DIEP, 4/16) and other minor complications (TRAM, 3/16; DIEP, 1/16). The mean hospital stay was 7.13 days (range, 4 to 12 days) for the pedicled TRAM group and 7.56 (range, 5 to 10 days) for the DIEP group. Neither the difference in complication rates nor in hospital stay duration were statistically significant. The total hospitalisation cost for the DIEP group was significantly higher than that of the pedicled TRAM group (P<0.001). Conclusions Based on our study, the pedicled TRAM flap remains a cost-effective technique in breast reconstruction when compared to the newer, more expensive and tedious DIEP flap.
DIEP flap
Fat necrosis
Rectus abdominis muscle
Abdominoplasty
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Bilateral prophylactic mastectomy can reduce the incidence of breast cancer by 87 to 93% in high-risk individuals and is an appealing option for many patients if reconstruction can be provided with acceptable morbidity and outstanding esthetic results. Autogenous breast reconstruction techniques have evolved over the last 20 years to meet this goal. Familiarity with the deep inferior epigastric perforator (DIEP) flap led us to carry out simultaneous bilateral breast reconstruction with acceptable morbidity and superior esthetic outcome in 3 patient groups: (1) after bilateral prophylactic mastectomy, (2) after therapeutic and contralateral prophylactic mastectomy, and (3) after explantation of bilateral implant failures. A retrospective review of our experience with 280 flaps in 140 patients was performed. Average operating times, including time for implant removal or mastectomy and reconstruction, was 7.3 hours. Average hospitalization was 3.9 days. Significant perioperative complications occurred in 9 patients (6.4%); all returned to the operating room. This included 7 microvascular complications, 1 hematoma, 1 seroma, and 1 DVT. Less significant complications were divided into early and late. The early complications included 1.8% partial flap necrosis, 4.2% abdominal apron necrosis greater than 5 cm2, 2.9% seromas that required intervention, and 5.7% partial breast flap dehiscence. Late complications included 12.5% fat necrosis of any size and 2.1% hernia formation. Smoking, obesity, age, history of chest wall radiation, and flap size were evaluated as risk factors for increased morbidity.
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Fat necrosis
Seroma
Wound dehiscence
Prophylactic Mastectomy
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The transverse rectus abdominis musculocutaneous (TRAM) flap has become the procedure of choice for autologous breast reconstruction after mastectomy in the past decade. Despite the numerous advantages of the free TRAM flap, abdominal wall complications are the major concerns for plastic surgeons performing breast reconstruction with TRAM flaps. Since the report of successful breast reconstruction with the free deep inferior epigastric perforator (DIEP) flap by Allen and Treece in 1994, there has been increasing use of the free DIEP flap for breast reconstruction in recent years. The reported results of the free DIEP flaps were comparable to those of the free TRAM flaps, though there might be slightly increases of rates of partial flap loss and fat necrosis. However, the abdominal wall complications could be eliminated. After the experiences of breast reconstructions with free TRAM flaps, we chose the free DIEP flap as our procedure for the breast reconstruction after mastectomy for recent 10 cases. There was no total or partial flap loss. The results were cosmetically acceptable, though the dissections of perforators were tedious. We believe the free DIEP flap is an excellent technique that can obtain a successful, autologous tissue breast reconstruction with minimal donor-site morbidity.
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Fat necrosis
Rectus abdominis muscle
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DIEP flap
Fat necrosis
Rectus abdominis muscle
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DIEP flap
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The aim of this study was to analyze outcomes of patients who had prior abdominal operations and underwent DIEP flap breast reconstruction and to describe technical strategies to insure well‐vascularized flap‐harvest minimizing abdominal donor‐site complications. All patients who underwent DIEP flap breast reconstruction between 2004 and 2014 were reviewed and divided into a control group (CG) and a scar group (SG). Patient demographics, operative details, flap and donor‐site complications were analyzed and compared. For all of the scars, DIEP flap design was not modified, but a standardized approach was developed according to the type and location of the scar, available vascular pedicle, perforator locations, and the required flap tissue for breast reconstruction. Two hundred and eighty patients underwent 292 flaps in CG and 107 underwent 111 flaps in SG. Pfannenstiel, McBurney, laparoscopic, midline and subcostal were the most common previous incisions. There were no significant differences between groups regarding demographics, flap and mastectomy weight, active smoking, or radiation status ( P > 0.05). No significant differences were observed in DIEP flap loss ( P = 0.909), partial flap loss ( P =0.799), or fat necrosis ( P =0.871) and in the rate of abdominal donor‐site complications between groups ( P > 0.05). SG had a significantly higher mean operative time than CG ( P =0.034). Medial raw was a negative risk‐factor for flap complications, while BMI (>25.1 kg/m 2 ) and smoking‐history were significant predictors for donor‐site complications. With careful preoperative planning and appropriate technical strategies, successfully DIEP flap breast reconstruction can be performed without increased flap and donor‐site complications in patients with preexisting abdominal scars. © 2015 Wiley Periodicals, Inc. Microsurgery 37:282–292, 2017.
DIEP flap
Fat necrosis
Rectus abdominis muscle
Demographics
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