1607 Seeing White: Management of TIVA During Autologous Breast Reconstruction
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Abstract Background Free flap surgery has inherent risks, and the venous drainage of the Deep Inferior Epigastric Perforator (DIEP) flap is particularly vulnerable to congestion. In these cases, an algorithm for flap salvage should be followed and one of the final steps in this process is a cephalic vein transposition. Case Report We describe two patients undergoing mastectomy and immediate bilateral DIEP breast reconstruction, where cephalic vein transposition was required. As part of the Enhanced Recovery After Surgery (ERAS) pathway, patients are anaesthetised with a continuous propofol infusion (Total Intravenous Anaesthesia; TIVA). When the cephalic vein was identified, the propofol infusion was visible within the vein, which would have interrupted TIVA if harvested. To maintain continuous TIVA infusion, the cannula was resited prior to harvest of the cephalic vein. The cephalic vein was anastomosed to the superficial inferior epigastric vein and resolution of the venous congestion was noted. Conclusions These cases although rare highlight the importance of robust preoperative planning and communication between the team and preparation for all eventualities to ensure patient safety and successful outcomes. These cases highlight the potential effects vein harvesting or transposition may have on the safe and effective delivery of anaesthetic agents and other medication. We hope these cases prompt a discussion in the preoperative stage for alternate strategies for monitoring and intravenous access in response to diversions from the standard operating procedure.Keywords:
Cephalic vein
DIEP flap
Abstract The deep inferior epigastric perforator (DIEP) flap is widely recognized as safe for use as a first-choice option in autologous tissue breast reconstruction; however, DIEP is often not performed for breast reconstruction in the elderly. We report a case of an 85-year-old woman who underwent DIEP flap reconstruction. Immediate reconstruction was performed after mastectomy. The patient successfully underwent DIEP flap reconstruction with no complications. Other options for reconstruction include a latissimus dorsi flap, a transverse rectus abdominis flap and implant-based reconstruction. DIEP flap reconstruction was performed, which does not cause muscle damage and provides sufficient volume. To our knowledge, this study is the first to report DIEP breast reconstruction in a patient over 85 years of age. This case demonstrates the usefulness of DIEP flap reconstruction for elderly patients.
DIEP flap
Rectus abdominis muscle
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Background: Every year many patients diagnosed with breast cancer are subjected to mastectomy. Some of them choose to undergo breast reconstruction to restore their body image. Immediate or delayed reconstruction is possible, depending on medical, financial, and emotional considerations. High success rate and cost-effectiveness are two important factors that may guide decision making in the management plan. The objective of this study was to compare the resource costs and success rates of immediate and delayed breast reconstructions using either deep inferior epigastric perforator (DIEP) or superficial inferior epigastric artery (SIEA) flaps. The resource cost is referred to as the cost of operation and hospitalization. Methods: From September of 2000 through August of 2001, 42 patients underwent immediate (n = 21) or delayed (n = 21) unilateral breast reconstruction using either a DIEP (n = 30) or SIEA (n = 12) flap by one surgeon. Results: There were no statistical differences in resource costs, success, and complication rates between DIEP and SIEA flaps in both the immediate and delayed breast reconstruction groups. Conclusions: Using either a DIEP or SIEA flap as the autologous tissue, delayed breast reconstruction is as cost-effective as immediate reconstruction.
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Background: The continuing advances in breast reconstruction surgery allows for high expectation of excellent outcomes and long-term aesthetic appearance. Transverse rectus abdominis muscle (TRAM) flap has been the flap of choice in breast reconstructions for decades, however it sacrifices muscle and causes donor site complication. Deep inferior epigastric perforator (DIEP) flap is now the preferred flap for microsurgical breast reconstruction, because it holds some advantages over TRAM. This study aim to review, summarize, and discuss the current knowledge of DIEP flap in breast reconstruction.Method: Literature research conducted through Pubmed, Medline, and SCOPUS databases for published articles up to the year 2009. A total of 808 articles were found, and 60 articles reviewed.Result: Women with thick subcutaneous fat and skin on the lower abdomen are the most appropriate candidates for autologous breast reconstruction. Patients might be given oral analgesics instead of intravenous, because DIEP results in less postoperative pain than TRAM. Patients are commonly discharged on the 6–7th day post operation after DIEP flaps. In spite of several reports that DIEP flap has low complication rates, necrosis is the most common and often leads to poor cosmetic outcome.Conclusion: DIEP flap essentially combines all the advantages of TRAM flap without most of its disadvantages. Some complications may occur in smaller percentage. Although DIEP flap has a high patient satisfaction score, it does not mean that it is definitely superior to other methods of autologous breast reconstruction.
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Rectus abdominis muscle
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ABSTRACT 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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Reconstruction with a Deep Inferior Epigastric Perforator (DIEP) flap is considered to be the first choice forautologous breast reconstruction. Skin and fat are transplanted from the lower abdomen to the chest were theblood vessels are reconnected through microsurgery. A total of 309 patients with unilateral DIEP flap and 23patients with expander prosthesis (EP) reconstructions were included in the present studies aimed at illustratingand optimizing breast reconstruction with the DIEP flap technique.We evaluated blood flow before and after indirect heating, as well as sensitivity to touch, cold and warmth in tenwomen with reconstructed DIEP flaps. Indirect heating caused a significant increase of blood flow in both DIEPflaps and control breasts, and all patients regained some sensation of touch, cold and warmth.Surgery time and complication rates were studied in 64 patients randomized to preoperative mapping ofperforators with computer tomography angiography (CTA) or hand-held Doppler ultrasound (US) prior to DIEPsurgery. Surgery time and complication rates were nearly the same in the two groups.We studied 301 charts of patients with DIEP flap reconstructions to elucidate the impact of smoking habits andBody mass index (BMI) on complication rates. We discovered a significantly increased rate of donor sitecomplications in former smokers but differences in BMI did not make a significant difference in complications.Fifty patients were studied to assess early differences in health care consumption and complication rates followingdelayed breast reconstruction in non-irradiated women with DIEP flap or EP. DIEP reconstruction was a morecomplex and more health care consuming operation compared to EP surgery, which was often an easier solutionfrom the start. In summary, a DIEP flap reconstruction has its advantages and these might be even more obviousin the long run when aspects of patient satisfaction and quality of life can be observed. (Less)
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A recent article by Kaplan and Allen suggested that deep inferior epigastric perforator (DIEP) flap breast reconstruction was less expensive than reconstruction performed with free transverse rectus abdominis musculocutaneous (TRAM) flaps. To test that hypothesis, a series of patients who had undergone unilateral breast-mound reconstruction by the first author using DIEP or free TRAM flaps between November 1, 1996, and March 30, 2000, were reviewed. Bilateral reconstructions and reconstructions performed by other surgeons in the department were excluded to eliminate all variables except the choice of flap. All hours in the operating room and days in the hospital until discharge were included. Early readmissions for the treatment of complications were included, as were the costs of the mastectomy in the case of immediate reconstructions, but late revisions and nipple reconstructions were not. The totals were then converted into resource costs in 1999 dollars, and the DIEP and free TRAM flap groups compared. There were 21 DIEP flaps and 24 free TRAM flaps in the series. In this series, there was no significant difference between the cost of DIEP and free TRAM flap breast reconstruction. (Plast. Reconstr. Surg. 107: 1413, 2001.)
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Objective To investigate the indications, advantages, surgical methods and effects of combined skin flap of the deep inferior epigastric perforator( DIEP) and the transverse rectus abdominis musculocutaneous( TRAM) and bipedicled DIEP flap for breast reconstruction. Methods From August 2003 to June 2006, secondary breast reconstruction were carried out in 29 cases. Of the 29 patients, 21 patients underwent reconstruction using the combined skin flap and 8 patients using bipedicled DIEP flap. Results The reconstructed breasts were well-shaped with the follow-up of 3-36 months. The distal portion of the flap necrosed in 1 case of the united flap group and necrosis of flap occurred in 2 cases of the bipedicled DIEP flap group. Fat necrosis occurred in 33.3% of the united flap and 12.5% in the bipedicled flap. Conclusion The procedure for breast reconstruction should be selected according to the patient’s status. Bipedicled DIEP flap could be used for breast reconstruction in the condition of recipient vessels intact, which could retain the maximal function of the rectus abdominal muscle and prevent the occurrence of abdominal weakness and hernia. The united flap possesses advantages such as rich blood supply, abundant tissue volume, and easy shaping. It is a reliable and safe technique for autologous breast reconstruction. The DIEP and TRAM united flap is a good choice for cases with impaired recipient vessels.
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Fat necrosis
Rectus abdominis muscle
Abdominal Hernia
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Background and Objective: The deep inferior epigastric artery perforator (DIEP) flap was first described by Koshima and Soeda in 1989 and is now well-established as the gold standard in breast reconstruction. Lately, this issue has been explored in the context of head and neck reconstruction, highlighting growing interest in the use of the DIEP flap beyond breast reconstruction, but its usage in other anatomical regions appears elusive. Nevertheless, DIEP flap reconstruction may be a viable choice for complex, three-dimensional head and neck deformities while upholding the criteria of minimal donor site morbidity, according to a recent review. To determine whether the DIEP flap may be used successfully in other types of reconstruction, we conducted a review on the use, applications, and outcomes of the DIEP flap in non-breast reconstruction. This is, as far as we are aware, the first comprehensive analysis of all applications of the DIEP flap other than for breast reconstruction. Methods: A literature review was performed using PubMed to include all relevant articles in English or French published up to February 2022. Keywords included "DIEP flap" and "deep inferior epigastric perforator flap". Key Contents and Findings: A total of 1,299 articles were identified with 105 on the use of the DIEP flap in non-breast reconstruction. This suggests increasing recognition of the DIEP flap as a feasible option for reconstruction of most anatomical regions, especially in lower limb and head and neck reconstruction, followed by gynecological reconstruction. The DIEP flap was also utilized in the reconstruction of upper limb, thigh and hip defects. Less commonly, it has been used for penoscrotal, groin, sternal, buttock and abdomen reconstruction. Conclusions: The scientific body of evidence showed the robustness and versatility of the DIEP flap in non-breast reconstruction, with its relative pros and cons at different anatomical regions.
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Breast reconstruction is a given choice for many women following mastectomy. There are a multitude of methods available today, and thus, comparative studies are essential to match patients with suitable methods. The aim of this study was to compare 5-year outcomes following delayed breast reconstruction with expander prosthesis (EP) and with deep inferior epigastric perforator (DIEP) flaps. Seventy-three patients, previously randomised to either a permanent EP or a DIEP flap breast reconstruction, were invited for a 5-year follow-up. Assessments included symmetry measurements, breast sensibility with Semmes-Weinstein monofilaments and patient-reported outcome (PRO) with the BREAST-Q. Complications within the first 5 postoperative years were recorded. Additionally, BREAST-Q questionnaires were collected from non-randomised patients with an EP breast reconstruction. Between 2019 and 2022, 65 patients completed the follow-ups. Symmetry and PRO were significantly higher in the DIEP flap group. However, EP-reconstructed breasts were significantly more sensate and demonstrated areas with protective sensibility, unlike the DIEP flap breasts. The overall complication rates were comparable between the two groups (p = 0.27). Regression analysis identified body mass index as a risk factor for reoperation in general anaesthesia and for wound infection. No significant differences were found in a comparison of the randomised and the non-randomised EP groups' BREAST-Q results. This randomised 5-year follow-up study found PRO to be favourable following a DIEP flap reconstruction and sensibility to be better in EP reconstructions. The complication rates were comparable; however, longer follow-ups are warranted to cover the complete lifespans of the two breast reconstruction methods.
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