Search

Breast cancer is the most common malignancy in women in the United States, with surgical options including lumpectomy and mastectomy followed by breast reconstruction. Deep inferior epigastric perforator (DIEP) flap is a muscle-sparing perforator free flap breast reconstruction technique, which uses the deep inferior epigastric artery (DIEA) perforators to create a vascular pedicle. Multiple perforators are identified by preoperative imaging, which are typically ranked based on size, location, and intramuscular course. The goal of preoperative imaging is to aid the surgical team in preoperative planning given the variability of the DIEA perforator branches anatomy between patients. The objective of this document is to review the imaging modalities that can be used preoperatively to identify the optimal perforator and thereby reduce intraoperative complications, reduce postoperative complications, and improve clinical outcomes. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances in which peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation. [ABSTRACT FROM AUTHOR]

Perforator flaps yield the best results for the patient with the least morbidity, and they should be considered the gold standard in head and neck reconstruction. Although deep inferior epigastric perforator (DIEP) flap is considered as the gold standard in breast reconstruction, its use in head and neck reconstructive surgery does not seem so widespread. The objective of this study is to conduct a systematic review of the use, applications and results of the DIEP flap in the head and neck area. Search was conducted in different indexed databases (PubMed/MEDLINE, the Cochrane Library, Scielo and Web of Science) and through meta-searcher Trip Database with deep inferior epigastric perforator flap AND head neck keywords. Studies on animal and human experiments published in peer-reviewed journals, where investigators assessed the use of DIEP flap, according to the Koshima criteria, in the head and neck area were considered. A total of 31 articles and 185 flaps with 95% of survival were found. Thrombosis or venous stasis is the most frequent cause of flap loss and 16.1% presented some type of complication, the most frequent being the dehiscence. The most use was in the reconstruction of glossectomy defect secondary to squamous cell carcinoma (30.51%), being able potentially to re-establish sensory innervation in oral cavity. The assessment of risk bias (National Institutes of Health) highlights the lack of uniformity, with no standardisation of the outcome variable collection and monitoring. By virtue of its versatility, reliable vascular supply and high flap survival rate, the DIEP flap reconstruction could be an option in complicated 3-dimensional head and neck defects while maintaining the standard of low donor site morbidity. [ABSTRACT FROM AUTHOR]

Summary: Microscopic arteriovenous anastomoses are known structures that have many clinical implications, with disease states such as Reynaud''s phenomenon and erythromelalgia known consequences of their abnormal functioning. These pre-capillary arteriovenous communications result in increased regional blood flow at the time of capillary filling. Recent advances in imaging technology, providing physiological and anatomical data, have identified a previously undescribed anatomical structure, that of large-vessel (macroscopic) arteriovenous communications, with profoundly different implications. Computed tomographic angiography (CTA) of the abdominal wall vasculature was undertaken in 140 patients prior to reconstructive surgery. All scans were arterial phase, demonstrating functional arteriovenous communications in all patients. These communications identified vascular shunting occurring prior to capillary filling. Fine-cut slices were able to visualise the structures, demonstrate their size as macroscopic (>1mm diameter) and map the course of the arteriovenous communications. The potential clinical implications and therapeutic possibilities in a range of medical and surgical conditions are described. [Copyright &y& Elsevier]

Summary: Background: While the deep inferior epigastric artery perforator (DIEP) flap is a reliable technique for autologous breast reconstruction, the meticulous dissection of perforators may require lengthy operative times. In our unit, we have performed 600 free flaps for breast reconstruction over 8 years and have reduced operative times with a combination of preoperative computed tomographic angiography (CTA), various anastomotic techniques and the Cook–Swartz implantable Doppler probe for perfusion monitoring. We sought to assess the feasibility of performing two DIEP flaps within the working hours of a single day. Methods: A review of 101 consecutive patients undergoing DIEP flap breast reconstruction in a 12-month period was performed, comparing one DIEP flap per day (n =43) to two DIEP flaps per day (n =58). Complications, outcomes and techniques used were critically analysed. For cases of two DIEP flaps per day, a comparison was made between the use of two separate operating theatres (n =44) and a single consecutive theatre (n =14). Results: Complications did not increase when two DIEP flaps were performed in a single working day. The use of vascular closure staple (VCS) sutures and ring couplers resulted in statistically significant reductions in anastomotic times. The use of two separate theatres for performing two DIEP flaps resulted in a reduction of 59min in operative time per case (p =0.004). Conclusion: Two DIEP flaps can be safely and routinely performed within the hours of a single working day. By minimising operative times, these techniques can improve productivity and substantially decrease surgeon fatigue. [Copyright &y& Elsevier]

Summary: This report highlights the case of an unusual bilateral breast reconstruction using bilateral Deep Inferior Epigastric Perforator flaps based solely upon unilateral perforators. The usual lower paramedian perforating vessels were absent on one side and subsequently the main abdominal flap was split obliquely (rather than midline) to base both individual flaps on perforators arising from the same side. The operation was a success with no flap complications post-operatively. [Copyright &y& Elsevier]

Breast cancer is the most common malignancy in women in the United States. Breast reconstruction surgery is a commonly used therapy for patients with breast cancer. The technique for the deep inferior epigastric perforator flap uses a preserved rectus muscle, which decreases donor site morbidity. Accurate identification and measurement of the perforator branches of the deep inferior epigastric artery is pivotal during pre-operative planning so that the surgeon can prioritize the best vessel to use and ultimately improve clinical outcome. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment. [ABSTRACT FROM AUTHOR]

Abstract: The transverse rectus abdominis musculocutaneous (TRAM) flap based on the deep inferior epigastric artery is useful in head and neck reconstruction as it provides substantial skin and soft tissue cover, and allows volume to be replaced in large defects. A major advantage is the anatomical reliability of the deep inferior epigastric pedicle. We report a case in which neither rectus abdominis muscles had a blood supply from the deep inferior epigastric artery, which necessitated a change in the planned reconstruction. We review variations in the anatomical course of the artery and, although rare, stress the importance of reconstructive surgeons being aware of such variations. [Copyright &y& Elsevier]