Search

Perforator-based flaps have become a mainstay of autologous breast reconstruction practice. Despite available radiological investigations ranging from Doppler ultrasound (US) to CT angiography (CTA), finding and quantitatively assessing perforators remains a time-consuming, complex process. Infrared thermographic imaging (IRT) shows promise as a novel modality for preoperative localisation of perforator vessels. Thirteen women undergoing elective breast reconstruction with deep inferior epigastric artery perforator (DIEAP) flaps were recruited between August 2017 and July 2018. All had CTA and Doppler US mapping of arterial perforators preoperatively as standard. Additional abdominal thermal images were taken using a FLIR ONE smartphone compatible camera. Thermal hotspots were compared with Doppler markings and CTA findings. Twenty-six flaps were analysed. Seventy perforators were marked by Doppler US, with a mean of 2.92 perforators per flap (± SEM 0.15, SD 0.72). Forty (57%) had a corresponding hotspot on IRT. Overall, there was a statistically significant positive correlation between the number of perforators detected by Doppler US and IRT (r = 0.573, n = 26, p = 0.003) and kappa index 0.65. Eighty-four perforators were identified by CTA, with a mean of 3.5 perforators per flap (± SEM 0.14, SD 0.66). Fifty-eight (69%) had a corresponding hotspot on IRT. There was a statistically significant positive correlation between the number of perforators detected by CTA and IRT (r = 0.504, n = 26, p = 0.012) and kappa index 0.60. Thermography is an inexpensive, portable, non-invasive imaging technique, which shows statistically significant correlation to CTA and Doppler US in mapping perforators. Level of evidence: Level IV, diagnostic study.

Background The deep inferior epigastric artery perforator (DIEP) flap is one of the most used free flaps for postmastectomy breast reconstruction. Prolonged ischemia can result in (partial) flap loss. The aim of this study was to evaluate the association between ischemia time and postoperative complications of DIEP flap breast reconstruction. Methods A retrospective study of all patients who received a breast reconstructionwith aDIEP flap atMaastricht University Medical Center in theNetherlands, between January 2010 and June 2017 (n = 677). The flaps were divided into two groups: flaps with an ischemia time less than 60 min and those with 60 min or more. Recipient site complications, in particular major complications equal to re-exploration, and partial or total flap loss were the primary outcome measures. Results In 23.9% of the 677 included DIEP flaps, the ischemia time was 60 min or longer. Within this group, a complication of the recipient site occurred in 30.9% of the flaps. A major complication occurred in 17.3% of the flaps with 60 min or more ischemia time.With regard to the flaps with less than 60-min ischemia time, a complication occurred in 22.1% of the cases of which 8.9%would be considered amajor complication. A significant association was found between ischemia time and major complications on univariate (p value = 0.003) and multivariate analyses (p value = 0.016). Conclusions This study demonstrates that an ischemia time less than 60 min is associated with a significantly lower risk of major recipient site complications compared to an ischemia time of 60 min or more. Level of evidence: Level III, therapeutic, risk/prognostic study.

The deep inferior epigastric artery perforator flap is the gold standard in microsurgical breast reconstruction. It is now increasingly offered in patients with previous abdominal scars and in such cases, computed tomography angiography (CTA) is routinely implemented. However, previous injury of the deep inferior epigastric vessels may be difficult to detect with CTA. We report three cases of successful bilateral breast reconstruction, in which a unilateral DIEA was found to be abnormal. In the first two cases, the unilateral DIE vessels were found to be damaged and the flaps salvaged based on the deep superior epigastric artery. In the third patient, previous DIEA injury resulted in vessel recanalization, which was only evident following initial anastomotic failure. In this case, the damaged DIEA segment was subsequently removed and the flap successfully revascularized. All three patients had an uneventful post-operative recovery and all flaps survived with no complications. Based on our experience, we believe that awareness of the potential pitfalls and careful planning for lifeboats are essential to avoid flap loss in such circumstances. Level of Evidence: Level V, therapeutic study.

Deep inferior epigastric artery perforator flap (DIEP/DIEAP) procedure is a common method for breast reconstruction after mastectomy. For unilateral breast reconstruction, harvesting of the flap can be done contralaterally or ipsilaterally. The aim of this study is to demonstrate a possible side difference in quality of abdominal skin perfusion from left to right and its causes, which could have implications on our selection of flap harvesting side, operating time, and flap design itself. We performed thermographic imaging after induced hypothermia of the abdominal skin in 17 females to evaluate the quality of blood supply to each side of the abdominal wall. Additionally, we examined the diameter of the deep inferior epigastric artery, whether there is a difference in size correlating to the quality of blood supply of each side. Evaluation of our pre-operative thermographic imaging method was performed in four patients which underwent unilateral DIEP flap reconstruction regarding reduction of surgery time and assessment of overall outcome. Every subject showed a dominant side of perfusion (greater area of perfusion after set time). Furthermore, we discovered a side difference between left and right diameter of the deep inferior epigastric artery in each patient (0.2-mm mean difference; p = 0.0002). The rewarming process of the abdominal skin was faster (16 out of 17 subjects; 94.1%) (greater area of rewarming after set time) on the side with the greater diameter deep inferior epigastric artery. In our DIEP patients using thermographic imaging of the abdominal skin, we only performed perforator dissection on the preferable side. The consequence was a reduction in operating time of 25 minutes compared to careful dissection of both sides. None of our patients showed complications such as wound-healing disorders. Thermographic assessment of the abdominal skin after hypothermia is easy to conduct and gives reproducible information about different areas of skin perfusion quality. The difference in rewarming speed from left to right is thought to be due to a larger diameter deep inferior epigastric artery, which translates into a superior perfusion, but does not necessarily correlate with the size of the perforators itself. The presented technique offers the potential to improve outcome, especially by lowering perfusion-related complications and reducing operation time by fast dissection of the non-dominant side while carefully dissecting the area of interest with fast thermographic rewarming results, and must therefore be investigated in future studies by measuring objective outcome results. Level of Evidence: Level III, risk/prognostic

Since the advent of free tissue transfer approximately 40 years ago, constant improvement particularly in the preoperative planning phase has led to flap success rate reaching 99% and improved patient outcomes. The use of imaging, such as computed tomographic angiography (CTA) or magnetic resonance angiography (MRA), for preoperative planning is now routine. However, current image modalities are restricted by being represented in two dimensions (2D) and have led to clinicians seeking novel methods of utilising the scan data, such as augmented (AR) or virtual reality (VR) and holograms. These mixed-reality devices facilitate a natural mode of visual perception and have the capacity to introduce tactile feedback. However, most AR devices are currently expensive, bulky and complicated and require tedious image registration processes. We illustrate our projector-based direct AR technique using CTA, or ARC, for preoperative planning. Our bespoke ARC method consists of compact, affordable hardware (MacBook, Philips pocket projector and a 15-cm ruler) and free, open-source software (OsiriX). We have utilised this technique in six cases of perforator flaps of the thigh and abdomen (anterolateral thigh (ALT), transverse upper gracilis (TUG) and deep inferior epigastric artery perforator (DIEP) flaps. In all cases, 3D-reconstructed images of perforators from CTA were accurately projected onto the donor site. System calibration was rapid and convenient to use. We illustrate a novel technique of projector-based AR CTA (or ARC) for preoperative planning in perforator flaps. The technique is affordable and readily reproducible. Level of Evidence: Level IV, diagnostic study.

The use of the deep inferior epigastric artery perforator (DIEP) flap has gained popularity as a technique for autologous breast reconstruction. This surgery entails finely dissecting the perforators of the deep inferior epigastric artery passing through the rectus abdominis muscle, while deciding which of the perforators will best supply the flap. Computed tomography angiography (CTA) has emerged as the imaging modality of choice for preoperative evaluation. This study evaluates the accuracy of CTA in identifying perforator anatomy and flap volume calculation, as well as its impact on the patient’s outcome. A prospective study was conducted. Thirty-two consecutive patients that underwent CT angiography prior to unilateral DIEP flap reconstruction surgery were included in the study. The control group was composed of 32 patients, who were operated on by the same surgical team, using the same surgical technique, prior to the initiation of the CTA study. The imaging provided by CTA was correlated with actual intra-operative findings. Operative time, the duration of hospital stay, and postoperative complications were assessed. The volume of the flap as calculated by CT was compared to the flap’s actual weight after harvest. CTA identified 285 perforators; of these, 278 were found intra-operatively. There was no statistically significant difference between the data provided by the CT and intra-operative findings. The use of CTA was associated with decreased operating time (unilateral, 424 versus 546 min, p

Despite the utility of the deep inferior epigastric artery perforator (DIEP) flap, the presence of abdominal wall scars can limit flap perfusion. Pfannnstiel scars are among the most common abdominal scars, during which undermining at either a subfascial or suprafascial level can damage perforators. There is an anecdotal belief that raising a DIEP flap in the presence of a Pfannenstiel scar may be less reliable due to vascular disruption. A clinical prospective analysis of retrospectively recorded imaging from 150 patients (300 hemi-abdominal walls) was undertaken. Preoperative imaging, with two computer software programmes used to reconstruct three dimensional (3-D) volume-rendered images and analyse vasculature, was used to accurately identify and measure perforators. A total of 959 perforators were identified, with 319 perforators identified in the ‘Pfannenstiel scar’ group and 640 perforators in the ‘no abdominal scar’ group. All patients, except for one patient with a Pfannenstiel scar, had one or more perforators that were larger than 1.0 mm in diameter. There were no differences in the number of DIEA perforators (6.81 vs 6.22, p = 0.2819); however, perforators of the ‘Pfannenstiel scar’ group were of larger mean diameter than the ‘no abdominal scar’ group (0.96 vs 0.85 mm (p = 0.0027). The presence of a Pfannenstiel scar is associated with larger perforator size than controls and no diminution in overall perforator number. As such, a Pfannenstiel scar may in fact aid DIEP flap harvest, a finding consistent with anecdotal outcomes. Level of Evidence: Level III, risk / prognostic study.

Traditionally, the vertical rectus abdominis muscle (VRAM) flap has been used as a robust and effective loco-regional reconstruction for perineal defects. We present a unique approach using a vertical skin paddle pedicled deep inferior epigastric artery perforator (DIEP) flap for the management of large perineal defects following colorectal tumour excision. As a colorectal and plastic surgery tertiary referral centre, over the last 5 years, we have developed a vast experience in reconstructing these defects in collaboration with our general surgical colleagues in the multidisciplinary setting. Our main reconstructions consisted of pedicled VRAM flaps, although we have used other local and free flap options when and as required. We have since moved towards this improved technique of the pedicled DIEP flap reconstruction and present our initial experience, highlighting its main advantages, particularly over the VRAM flap. Level of Evidence: Level V, therapeutic study.

For breast reconstruction, the deep inferior epigastric artery perforator (DIEAP) flap can be harvested at the same side as that in mastectomy (ipsilateral) or from the contralateral hemi-abdomen. This paper seeks to establish the benefits of either side of DIEAP flap harvest, on the basis of our experience and a literature review. We analysed our experience with the DIEAP flap and compared the two different technical approaches to flap harvesting. Using the internal mammary vessels as the standard recipient, with comparable vessels on either side, we compared the differences between harvesting on the contralateral and ipsilateral hemi-abdomen and analysed any references to it in the literature. Seventy-three DIEAP flaps were harvested for breast reconstruction, over a 2-year period, by the two senior authors. Of the 44 cases where the ipsilateral hemi-abdomen was used, this was the routine primary choice of the operating surgeon in 42 cases. The contralateral hemi-abdomen was the preferred choice in 29 cases. We accessed 302 papers related to the topic of breast reconstruction using a DIEAP flap, of which 63 papers were reviewed, based on the abstracts. Only six of these papers mentioned their routine or preferred choice of the hemi-abdomen. There appears to be no consensus in the literature as to the preferred side of DIEAP flap harvest, if the perforators are of similar calibre and ease of dissection. Modern DIEAP flap harvest is based on the preoperative selection of the most reliable perforator. In relation to mastectomy defect, this may be on the ipsilateral or contralateral. Level of Evidence: Level IV, prognostic/risk study

Breast reconstruction with autologous tissue is associated with numerous benefits. The Deep Inferior Epigastric Artery Perforator (DIEAP) flap aims to minimize the donor site morbidity. A significant learning curve has often been demonstrated with the introduction of this flap. We examined the outcomes and complications for our first 70 DIEAP flap reconstructions in 67 patients. We found no significant difference in any complication between the early and late groups. We found a significant decrease in the length of stay of patients from 7.4 to 5.9 days (P 0.037). There was a significant reduction in the length of delayed unilateral reconstructions operation from 554 to 480 minutes (P 0.038). Microsurgical breast reconstruction has been successfully introduced by a single surgeon, in a district general hospital (DGH).

The deep inferior epigastric artery perforator (DIEAP) flap is arguably the gold standard for autologous breast reconstruction. Despite its manifold advantages, potential flap failure, often secondary to venous congestion, is a devastating possible complication. An appropriate salvage procedure may avoid DIEAP flap loss. To identify, describe and analyse DIEAP flap salvage procedures carried out by the senior author (and Coventry and Warwickshire Hospital Plastic Surgery Clinical lead) who has a special interest in breast reconstruction, over an 8-year period. A retrospective analysis of notes and logbooks was carried out to identify DIEAP flap breast reconstructions that required salvage procedures involving anastomoses in addition to or other than the routine deep inferior epigastric artery (DIEA) and vein (DIEV) to internal mammary artery and vein (IMV). One hundred twenty-seven DIEAP reconstructed cases were identified of which seven required lifeboat procedures: (1) piggy back chimeric DIEAP/TRAM flap, (2) double barrelling and trouser legging IMV and DIEVs, (3) contralateral perforator anastomosis to stump of main ipsilateral DIEA, (4) venous graft and anastomosis to cephalic vein, (5) venous anastomosis to thoracodorsal vein and (6) multiple rib resection for friable radiotherapy damaged vessels. The DIEAP flap is an increasingly popular method of providing autologous breast reconstruction with good volume and reliable perforators. However, surgeons may find that the recipient vessels of choice or the perforators alone are not adequate to maintain a healthy, viable flap. We hope that knowledge of this department’s salvage options may add to methods described in the literature and therefore the armamentarium of others when faced with similar problems.

In this study, we evaluated the peri-operative abdominal drain volumes and length of hospital admission between our superficial inferior epigastric artery (SIEA) and deep inferior epigastric artery perforator (DIEP) patients to determine whether SIEA flaps were associated with increased post-operative abdominal drainage and length of hospital stay. We studied consecutive patients who had breast reconstruction using either a free SIEA (seven) or DIEP (28) flaps. All patients had abdominal drains inserted, and cumulative drainage measurements were taken every 24 h. Data on patient's age, BMI, length of hospital stay, smoking history, and abdominal fluid drainage were collected. Statistical analyses were performed using a t test (Mann–Whitney). A statistically significant difference (P = 0.029) was observed in the total abdominal drainage between the two groups. The mean drainage volume in the SIEA group was 2,248 ml and 531 ml in the DIEP group. No association was observed between smoking and drainage volume in the DIEP group. Similarly, obesity did not appear to influence drainage volumes in either the SIEA or the DIEP groups. The average length of stay for the SIEA group was 10.4 days and 9.1 days in the DIEP group, although this was not statistically significant (P = 0.351). While abdominal wall morbidity is reduced in patients undergoing an SIEA flap for breast reconstruction, in our series, we found that the SIEA flap was associated with a significant increase in abdominal drain volume relative to the DIEP flap, which translated to an extra day in hospital.

In this study, 70 consecutive cases of breast reconstruction with the use of a free Transverse Rectus Abdominal Myocutaneous (TRAM) flap were reviewed with respect to the type of recipient vessels. We describe our evolution of choice of the receptor vessels. The deep inferior epigastric artery was anastomosed to the thoracodorsal artery in 15 cases. In 55 cases the internal mammary artery (IMA) was used as a recipient vessel. The deep inferior epigastric vein was anastomosed to the thoracodorsal vein in 15 cases, to the cephalic vein in eight cases, the external jugular vein in 16 cases and to the internal mammary vein (IMV) in 31 cases. Total flap necrosis occurred in four cases. In an additional four cases there was partial necrosis requiring minor operative correction. In six cases venous outflow problems were the cause of flap necrosis. The external jugular vein (n = 3) and cephalic vein (n = 2) were relatively frequently involved in cases of venous outflow problems. One flap was rescued 5 days after surgery following venous thrombosis by inserting a vein graft. The IMA and vein proved to be reliable and easy to access as recipient vessels for anastomosing the vessels of the free TRAM.

The free transverse rectus abdominis myocutaneous (TRAM) flap has earned a prominent place in the armamentarium of the clinician performing breast reconstructive surgery. There is, however, significant morbidity associated with this flap. With the advent of the deep inferior epigastric artery perforator (DIEP) flap many of these disadvantages may be overcome. Early experience with this promising technique is presented.

Sir, The recurrence of pressure sores remains a problem in paraplegic patients. More than 35 % of operated patients will have a recurrence [1–3]. Recurrent ulcers can occur after fasciocutaneous flaps and also musculocutaneous flaps. Then, flaps must be parsimoniously used for covering pressure sores. The superficial inferior epigastric artery (SIEA) flap is well known as a free flap, especially for breast reconstruction. We report the interest of the SIEA propeller flap for covering a recurrent trochanteric pressure sore in a paraplegic patient. Mr. D. is a 52-year-old male, having a T3 paraplegia, secondary to a spinal cord injury 29 years ago. In less than 25 years, he experienced pressure sores in sacral, trochanteric, and ischiatic areas. On the right trochanteric region, he was successively treated by a tensor fascia lata myocutaneous flap, a vastus lateralis muscle flap, and a groin flap for two recurrences in 20 years. Recently, he developed another trochanteric pressure sore, associated with an osteoarthritis of the right coxofemoral joint (Fig. 1). The patient complained about hyperthermia and a limitation of the hip mobility (10° in flexion, 0° in adduction, and 0° in abduction), making the chest to bed transfers more difficult. A multidetector-row computed tomography was made to confirm the osteoarthritis and evaluate the cutaneous perforators of the abdominal region. No reliable perforators was found from the deep inferior epigastric artery, but the caliber (2.6 mm) and the course (130 mm) of the SIEA were appropriate to raise a skin flap. The larger direct perforator of the SIEA had a 1.2-mm caliber, a 41-mm length, and the ascendant directionality adequate for a large skin flap. The surgery started by a large excision of the infected soft tissues around the ulcer. A femoral head–neck resection was performed. After a large cleaning and freshening of the acetabulum, the origin of the SIEA was dissected. The dominant direct perforator was found and included in the flap. A skin paddle measuring 15 × 20 cm was raised. The flap was rotated up to 100° for covering the trochanteric defect, as a propeller flap [4] (Fig. 2). The donor site was primarily closed. The operative time was 3 h, including the femoral head–neck resection, flap raising, and coverage of the coxofemoral defect. The patient was completely healed 2 weeks postoperatively. No recurrence or postoperative infection occurred during a follow-up of 24 months (Fig. 3). At 1 month, the patient recovered a mobility of 65° (45–110°) in flexion, 20° (0–20°) in adduction, and 40° (0–40°) in abduction. The chest to bed transfers and the dressing were significantly improved postoperatively. Fig. 1 Preoperative view of the trochanteric pressure sore. A central suppurative fistula is surrounded with inflammatory skin lesions. This trochanteric ulcer is associated with an osteoarthritis of the right coxofemoral joint Fig. 2 Intraoperative view of the superficial inferior epigastric artery propeller flap. The superficial inferior epigastric artery (yellow arrow) is dissected at the lower part of the abdomen. The proximal dominant perforator and the superficial inferior epigastric ... Fig. 3 Postoperative view of the trochanteric reconstruction. The trochanteric area is completely healed without infection 24 months postoperatively. No recurrence has occurred 24 months after the surgery. A few visible longitudinal scar can ... Pressure sores reconstructive surgery in paraplegics is known for a high risk of recurrence. Musculocutaneous flaps have been mainly used for their thickness and blood supply in this indication. However, the results of this complex case confirm that there is no statistical difference in ulcer recurrence between myocutaneous flaps and fasciocutaneous flaps [5]. Reeducation and prevention of skin hyperpressure seem to be more important than a muscle transfer. This case also reports the interest of the SIEA flap when classical flaps are not available for local reconstructions, and when no reliable perforators (>0.5 mm) are present for a deep inferior epigastric perforator flap. The SIEA flap can be safely rotated around its pedicle, as a propeller flap, without venous congestion or flap necrosis. It is a versatile flap for the coverage of large and infected trochanteric pressure sore.

Free flaps based on the deep inferior epigastric artery are known to be easily raised and offer a long and reliable vascular pedicle. According to the defect size and consistency, they can be raised as muscular, myocutaneous and as a sandwich flap, including the peritoneum [5]. A free flap consisting of only the peritoneum has been speculated on. Seventeen dissections on fresh cadavers were performed. The visualization of the vascular pedicle was obtained by blue dye coloration, contrast medium angiography, and intravascular silicone latex injections. It was found that the parietal peritoneum of the lower abdomen was constantly supplied by an axial branch of the deep inferior epigastric artery and not by muscle perforators.