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Chronic hand ischemia causes cold intolerance, intractable pain, and digital ulceration. If ischemic symptoms persist despite pharmacologic treatments, surgical interventions should be considered. This retrospective study evaluated the long-term results after ulnar and radial reconstruction using an interpositional deep inferior epigastric artery (DIEA) graft combined with periarterial sympathectomy. Patients who underwent this surgery from March 2003 to February 2019 were included. To evaluate variables influencing recurrence after the procedure, patients were divided into the recurred and non-recurred groups and their data were compared. Overall, 62 cases involving 47 patients were analyzed (16 and 46 cases in the recurred and non-recurred groups, respectively). The median DIEA graft length was 8.5 cm. The rates of rheumatic disease and female patients were significantly higher in the recurred than in the non-recurred group, without significant between-group differences in postoperative complication rates. In the multivariate analysis, underlying rheumatic disease and graft length had significant effects on recurrence. In Kaplan–Meier analysis, the 5- and 10-year symptom-free rates were 81.3% and 68.0%, respectively, with lower rates for cases with rheumatic disease. Thus, arterial reconstruction using an interpositional DIEA graft provides long-term sustainable vascular supply in patients with chronic hand ischemia, especially in those without rheumatic disease.

OBJECTIVE The aim of the study was to compare computed tomography (CT) angiography (CTA) imaging of deep inferior epigastric artery perforator (DIEP) using the ultrahigh-resolution CT (UHRCT) and conventional multidetector CT (MDCT). METHODS This retrospective study enrolled 20 patients who underwent CTA of DIEP flap with UHRCT and MDCT. Computed tomography values were measured at 4 large vessels (thoracic aorta, abdominal aorta, common iliac artery, and external iliac artery) and 5 peripheral vessels (proximal and distal internal thoracic artery, proximal and distal deep inferior epigastric artery, and DIEP). RESULTS There were no significant differences in mean CT values of the major vessel between UHRCT and MDCT. Ultrahigh-resolution CT shows higher CT values of the peripheral vessels than MDCT (P < 0.05 for all). The median CT values of the DIEP in UHRCT were approximately 3 times higher than those in MDCT (P < 0.001). CONCLUSIONS Ultrahigh-resolution CT provides higher-quality CTA of DIEP compared with MDCT.

BACKGROUND: The length of the amputation stump is crucial for optimal prosthetic fitting and rehabilitation. Especially in traumatic amputation, direct closure of the stump may be challenging, and bone shortening is frequently needed. To avoid excessive bone shortening, coverage of exposed bone with free flaps is a versatile option. OBJECTIVE: Here we present our experience with the utilization of free flaps from the lower abdomen for the coverage of amputations stumps of the lower extremity. METHODS: Between March 2008 and October 2010, five patients (three female, two male) with complex wounds on amputation stumps of the lower extremity were treated with a mean age of 50 years (range: 15–72 years). Six abdominal free flaps were performed in five patients (one bilateral case), including four deep inferior epigastric artery (DIEP-) and two muscle-sparing transverse rectus abdominis muscle (ms-TRAM-) flaps. Patient’s and operative data were collected retrospectively. RESULTS: One complete flap failure occurred (overall success rate: 83.3%). Three of five patients gained full ambulatory status. CONCLUSIONS: Due to the low donor site morbidity a long vascular pedicle and the large amount of available tissue, abdominal based free flaps represent our first choice for microsurgical reconstruction of lower extremity stumps.

Mobile smartphone thermal imaging (MTI) devices correlate with blood flow, which makes them appealing adjuncts during reconstructive surgery. MTI was assessed in the setting of deep inferior epigastric artery perforator (DIEAP) free flaps. We hypothesized that MTI can be a surrogate for blood flow to identify microvascular flow insufficiencies.Nineteen patients underwent 30 DIEAP flaps for breast reconstruction. Images were obtained preoperatively, intraoperatively, and at instances of concern for flap viability. Three groups were evaluated: normal DIEAP flaps (NDFs), flaps with arterial insufficiency (AI), and flaps with venous congestion (VC).All flaps were successful. There were significant temperature increases from max ischemia (24.5 ± 2.1°C) to 1 min after anastomosis (27.2 ± 1.6°C, P 0.001). NDFs continued to warm until the final MTI was taken when leaving the operating room. There were no differences between MTI flap temperatures before transfer to the chest and after completion of microanastomosis. With questionable flap viability, VC and AI temperatures were found to be significantly colder than the NDF group (28.3 ± 1.9°C versus 32.2 ± 1.8°C, P = 0.003) in the VC group and (27.2 ± 0.7°C versus 32.2 ± 1.8°C, P = 0.001) in the AI group. After correction of the identified flow insufficiency, VC and AI rewarmed and temperatures were no different compared with NDF.MTI recognizes microanastomotic failure and is a practical adjunct in the evaluation of free flap perfusion.

BACKGROUND The internal mammary artery/vein (IMA/V) are commonly used recipients for free flap breast reconstruction, but requires costal cartilage resection and limits future use of the IMA. This study aimed to evaluate the feasibility of the thoracoacromial artery/vein (TAA/V) as recipients for deep inferior epigastric artery perforator (DIEP) flap breast reconstruction compared with using the IMA/V. METHODS Medical charts of patients who underwent free DIEP flap breast reconstruction using the TAA/V or the IMA/V as recipient vessels were reviewed. Patient and vessel characteristics, time for vessel preparation and anastomosis, and postoperative pain were compared between TAA/V and IMA/V groups. RESULTS Thirty-four patients were included; 12 in TAA/V group, and 22 in IMA/V group. There was no flap failure in both groups. There were statistically significant differences between TAA/V and IMA/V groups in vessel preparation time (10.9 ± 3.7 min vs. 24.1 ± 6.0 min, p

Introduction When a Deep Inferior Epigastric Artery flap is not suitable, the Profunda Artery Perforator (PAP) flap can be a good alternative for autologous breast reconstruction. Popularity of the PAP flap is expanding, but it is still only slowly being adopted worldwide. We report our experience with 116 consecutive PAP flaps showing refinements and evolution of the technique towards improvement in outcomes and patients' satisfaction. Methods We prospectively collected data from consecutive PAP flap breast reconstructions performed from 2016 to 2019. Patients' demographics, pre-, intra-, postoperative data and revision procedures were analyzed. The BREAST-Q and a specific questionnaire investigating outcomes at the donor site were completed preoperatively and 12 months postoperatively. Results One-hundred and sixteen PAP flaps were performed in 86 patients, 64 unilateral and 22 bilateral breast reconstructions. Mean body mass index was 24.72 kg/m2 (range 18.9-29.2) and mean flap weight was 251.30g (range 152g – 455g). Complications included donor site hematoma (1.7%), seroma (2.6%), fat necrosis (1.7%) and wound dehiscence (2.6%). No arterial/venous thrombosis nor flap losses were recorded. Patients reported high satisfaction in all BREAST-Q domains, with mean postoperative scores being higher than preoperative ones, suggesting a positive effect in quality of life and satisfaction. Scores were significant in the satisfaction with breast domain (p= 0.0016). Conclusions Breast reconstruction with PAP flap yields a high success, low complications and excellent cosmetic outcomes in the breast and donor sites. It improves patients' satisfaction and quality of life; hence it can be considered an excellent option for autologous breast reconstruction.

Background: The deep inferior epigastric artery perforator (DIEP) flap is the gold standard in autologous breast reconstruction. When the abdomen is not available, alternative donor sites can be found at the buttock, the lumbar region, or the thighs. These flaps are referred to as second-choice flaps. This study compares the superior gluteal artery perforator (SGAP) flap and the lumbar artery perforator (LAP) flap to the DIEP flap using patient-reported outcomes. Methods: A retrospective study was performed reviewing the records of 417 women who underwent a free flap breast reconstruction with either a DIEP, an LAP, or an SGAP flap, between 2006 and 2018. Patients were asked to fill out the BREAST-Q questionnaire, and patient-reported outcomes were analyzed and correlated to the demographic information. Results: The response rate was 54.5 percent, with 50 LAP, 153 DIEP, and 25 SGAP flap patients participating. When questioned about their satisfaction with breasts and satisfaction with outcome, all three procedures were rated similarly high. When comparing the physical well-being of the donor site and appearance of the donor site, LAP flap patients reported significantly lower scores than DIEP and SGAP flap patients. Conclusions: Patients who undergo LAP or SGAP flap breast reconstruction seem similarly satisfied with the appearance and outcome of their free flap breast reconstruction compared with DIEP flap patients. The donor-site morbidity and its impact on the patient's well-being in SGAP and LAP flap patients have been underestimated. Despite more donor-site discomfort, the LAP and SGAP flaps are feasible alternatives whenever the DIEP flap is not possible.

Background Several patient-related factors have been identified with regard to the safety and efficacy of breast reconstructions. Using the largest database available in Europe, the presented study investigated the impact of cigarette smoking on deep inferior epigastric artery perforator (DIEP) free-flap breast reconstructions. Methods In total, 3,926 female patients underwent 4,577 free DIEP-flap breast reconstructions after malignancies in 22 different German breast cancer centers. The cases were divided into two groups: nonsmokers (NS) and smokers (S). Impact of smoking on surgical complications, controlled for covariates, and cluster effects within the cancer centers were analyzed by using generalized linear mixed models. Results Overall, there was no significant difference between the groups of patients regarding the rate of total flap loss. However, the rate of partial flap loss (0.9 vs. 3.2%, p Conclusion Our findings suggest that successful free tissue transfer can be achieved in smokers despite higher rates of partial flap losses and wound-healing disturbances. However, patients with a history of smoking requiring DIEP flap reconstruction should be critically evaluated preoperatively, informed in detail about the higher risk of complications and encouraged to quit smoking prior to surgery.

Background Total extraperitoneal laparoscopically assisted harvest of the deep inferior epigastric vessels permits a decrease in myofascial dissection in deep inferior epigastric artery perforator flap breast reconstruction. The authors present a reliable technique that further decreases donor-site morbidity in autologous breast reconstruction. Methods The authors conducted a retrospective cohort study of female subjects presenting to the senior surgeon (S.K.K.) from March of 2018 to March of 2019 for autologous breast reconstruction after a newly diagnosed breast cancer. The operative technique is summarized as follows: a supraumbilical camera port is placed at the medial edge of the rectus muscle to enter the retrorectus space; the extraperitoneal plane is developed using a balloon dissector and insufflation; two ports are placed through the linea alba below the umbilicus to introduce dissection instruments; the deep inferior epigastric vessels are dissected from the underside of the rectus muscle; muscle branches and the superior epigastric are ligated using a Ligasure; and the deep inferior epigastric pedicle is ligated and the vessels are delivered through a minimal fascial incision. The flap(s) is transferred to the chest for completion of the reconstruction. Results Thirty-three subjects totaling 57 flaps were included. All flaps were single-perforator deep inferior epigastric artery perforator flaps. Mean fascial incision length was 2.0 cm. Sixty percent of subjects recovered without narcotics. Mean length of stay was 2.5 days. Flap salvage occurred in one subject after venous congestion. Two pedicle transections occurred during harvest that required perforator-to-pedicle anastomosis. Conclusion Total extraperitoneal laparoscopically assisted harvest of the deep inferior epigastric pedicle is a reliable method that decreases the donor-site morbidity of autologous breast reconstruction. Clinical question/level of evidence Therapeutic, IV.

Background Reconstruction of intrapelvic soft tissue defects traditionally relies on regional pedicled myocutaneous flaps. However, there remain situations in which local options are unavailable. We review our experience treating intrapelvic defects with the anterolateral thigh (ALT) microvascular free flap. Methods A retrospective, institutional review was conducted from 2014 to 2018 of patients undergoing microvascular ALT flap reconstruction of intrapelvic defects. Four patients were identified in this cohort out of 92 total pelvic reconstruction cases. Results All patients underwent abdominoperineal resection (APR) for rectal cancer treatment. In the two male patients, pelvic abscesses and bladder leak necessitated soft tissue reconstruction after radiation and APR. In both, regional tissue options were unavailable, and a buried ALT free flap was used for soft tissue reconstruction. Both female patients developed rectovaginal fistulas secondary to their tumor burden, necessitating posterior vaginal wall resections. Prior surgical scars and ostomies made abdominal wall tissue unavailable; thus, free ALTs were used to eliminate intrapelvic dead space and reconstruct the posterior vaginal wall. In all cases, recipient vessels were the deep inferior epigastric artery and vein. Flap survival was 100%. Conclusions Pelvic reconstruction has traditionally been addressed with local/regional pedicled flaps. In cases where these are unavailable, the free ALT flap is a versatile option when buried for intrapelvic reconstruction or posterior vaginal wall lining. We also propose updating Cordeiro et al.'s classic vaginal defect reconstruction algorithm to include the free ALT flap for type IB cases in which the rectus abdominis is unavailable.

Background Phalloplasty often requires free tissue transfer. There is ample literature describing flap-related outcomes, but the microsurgical technique used, including choice of recipient vessels, has been an overlooked yet important topic. In this study, the authors review the outcomes of their experience with the deep inferior epigastric artery and locoregional veins and outline technical modifications that occurred during the study period. Methods A retrospective chart analysis of patients who underwent microsurgical phalloplasty between September of 2016 and July of 2019 was performed. Variables included flap design, donor site, and recipient vessels. The outcome measures were return to the operating room for flap compromise and partial or complete flap loss. Results Forty-two phalloplasties using the deep inferior epigastric artery were identified. There were six take-backs for flap compromise, and four patients required venous revision, one of whom lost his urethral flap on postoperative day 9. There was a decrease in take-back rate from 30 percent in the first 20 patients to 0 percent in the second 22 patients in the study period. A total of 11.9 percent of patients had partial flap loss. This decreased from 15 percent to 9 percent in the two groups. Conclusion After an initial learning curve, the combination of deep inferior epigastric artery, deep inferior epigastric vein, and great saphenous vein combined with specific technical modifications such as targeted coagulation of the vasa nervorum of the clitoral nerve has proven to be a reliable technique. Clinical question/level of evidence Therapeutic, IV.

The aim of the study was to investigate the relationship of BMI and abdominal wall thickness (AWT) with the diameter of the dominant deep inferior epigastric artery perforator (DIEP) as well as DIEA branching pattern in preoperatively performed computed tomography angiography (CTA).We conducted a retrospective study including all patients undergoing DIEP flap breast reconstruction with available CTAs from November 2013 to April 2018 in our department. The caliber-strongest DIEP was detected after passage of the rectus fascia as well as the superficial inferior epigastric artery (SIEA) and correlated with the AWT 5 cm above and below the umbilicus, lateral at the level of the umbilicus and at the level of the anterior superior iliac spine (ASIS), and with BMI.Seventy-seven patients met the inclusion criteria (age: 47.3 ± 8.9 years). We observed a significant relationship (p 0.05) between DIEP (mean ∅ = 2.98 mm) and BMI (r = 0.353), the AWT supra- and infraumbilical (r ≥ 0.32), and the AWT lateral at the level of the umbilicus and ASIS (r ≥ 0.25). In addition, there was a highly significant correlation (p 0.01) between SIEA and BMI (r = 0.389) and between the AWT lateral at the level of ASIS (r ≥ 0.41).We demonstrated a correlation of the diameter of the dominant DIEP with both BMI and AWT. Focusing on the diameter, in patients with a high AWT at the level of the ASIS, the SIEA, if present, may represent an alternative therapeutic option.

BACKGROUND: Autologous fat grafting (AFG) has been established over the past two decades as an additive technique during and after breast reconstruction. Complete reconstruction of the breast mound with AFG alone represents an exceptional technique that has been published mostly in case reports or in studies with limited cases. The purpose of this study is to investigate the influence of three different techniques for breast reconstruction on the recovery of skin sensitivity at the reconstructed breast. METHODS: The study included 30 patients after mastectomy following breast cancer. Three groups were examined: A) breast reconstruction by autologous fat grafting (AFG), B) breast reconstruction by deep inferior epigastric artery perforator flap (DIEP) and C) breast reconstruction by expander/implant (TE). Biometric data were compared; sensitivity tests were performed using Semmes-Weinstein monofilaments. The non-operated, healthy contralateral breasts of the patients were used as a reference. RESULTS: While the traditional reconstruction techniques by microsurgical anastomosed perforator flap or expander/implant showed a strongly decreased or completely missing sensitivity of the skin, the tests after reconstruction by AFG represented high values of sensory recovery, which came close to the reference group of non-operated breasts. CONCLUSION: To our knowledge, this is the first study to compare skin sensitivity after AFG-based reconstruction to established techniques for breast reconstruction. We could demonstrate in a limited group of patients, that breast reconstruction by autologous fat grafting can achieve higher values of skin sensitivity compared to traditional techniques.

SUMMARY One key component of a successful autologous breast reconstruction is insetting the flap to accurately resemble an aesthetic breast. The authors describe a novel technique used to shape a deep inferior epigastric artery perforator flap into a coned breast mound before introducing it into the breast pocket. With the flap perfusing on the chest wall, an area of skin estimating the size and location of the skin paddle is marked. The skin to be buried is then deepithelialized. Once hemostasis is ensured, the shaping is performed. Two 2-0 polydioxanone sutures are anchored in the Scarpa fascia at the 10- and 2-o'clock positions and then run at the level of the Scarpa fascia to the 6-o'clock position. The two sutures are then cinched together to achieve the desired shape and then tied. The flap is then placed in the breast pocket and secured into place at the inferomedial and inferolateral corners, and at its cranial aspect. The size of the skin paddle can then be finalized. In the authors' series of 21 breast reconstructions in 11 patients using flap preshaping, they have not seen any compromise in flap perfusion, with one patient showing a small area of secondary fat necrosis. In addition, the flaps maintained their aesthetic breast shape throughout follow-up. The authors believe this technique for shaping inferior epigastric artery perforator flaps before inset into the breast pocket to be both safe and predictable, simplifying one of the more tedious aspects of autologous breast reconstruction.

Background The superficial fascial system is routinely closed to alleviate tension at the abdominal donor site after harvest of the deep inferior epigastric artery perforator flap (DIEP) for breast reconstruction. This is thought to decrease rates of wound dehiscence and improve contour postoperatively. There has been no comparative analysis on closure of the superficial fascial system and its effect on donor-site outcomes. Methods The authors retrospectively evaluated outcomes of DIEP flap breast reconstructions performed between 2017 and 2019. After May of 2018, the surgeons collectively agreed to stop closure of the superficial fascial system. All subsequent patients underwent closure of rectus abdominis fascia followed by skin closure. Patient demographic data and abdominal donor-site comorbidities were recorded between the superficial fascial system closure and no-superficial fascial system closure groups. Representative photographs of patients from the two groups were blindly assessed for scar appearance and contour using previously published grading scales. The results were compared. Results DIEP flap breast reconstruction was performed in 103 consecutive women. Among patients with abdominal donor-site reconstruction, 66 had superficial fascial system closure and 37 did not. There was not a significant difference in fat necrosis or wound dehiscence between the two groups (p = 0.29 and p = 0.39, respectively). Postoperative abdominal scar and contour were evaluated by 10 independent raters and showed no significant difference between the two groups. Conclusion Omission of superficial fascial system closure resulted in no difference in wound dehiscence or fat necrosis rates and aesthetic appearance of the abdominal scar and contour. Clinical question/level of evidence Therapeutic, III.

Background The lumbar artery perforator flap is a second-choice flap in autologous breast reconstruction whenever a deep inferior epigastric artery perforator (DIEP) flap is not possible. Ideal candidates are pear-shaped women who do not have enough bulk on the abdomen or thighs. Patient-reported “satisfaction with breasts” is excellent but we were curious about the donor site morbidity. Methods We performed a retrospective study of all lumbar flap breast reconstructions performed between 2010 and 2019. Patients were invited by e-mail and telephone to take part in a BREAST-Q survey. Results One hundred fifty-four flaps were performed in 110 patients. Sixty-three patients filled out the BREAST-Q questionnaire. The most frequently observed donor site complications are seroma (35.1%), dehiscence (8.4%), and hematoma (3.2%). Correction of the donor site scar was performed in 31.8% of patients, lipofilling of the donor flank in 5.2%, and liposuction of the contralateral flank in 18.3% of patients. Body mass index (BMI) was the only significant risk factor for donor site complications. Patient-reported “satisfaction with donor site appearance” was good but significantly lower for primary reconstructions compared with secondary and tertiary procedures. Flap weight significantly influences patient-reported “physical wellbeing of the donor site.” Ninety-seven percent of patients would recommend the surgery to someone in a similar position and would do it all over. Conclusion The lumbar artery perforator flap is a good alternative for breast reconstruction in selected patients. The donor site issues consist mainly of seromas, prolonged discomfort, and a scar that might be noticeable to others, but patient-reported satisfaction is very high.

Background Advancements in three-dimensional (3D) printing have enabled production of patient-specific guides to aid perforator mapping and pedicle dissection during abdominal flap harvest. We present our early experience using this tool to navigate deep inferior epigastric artery (DIEA) topography and evaluate its impact on operative efficiency and clinical outcomes. Patients and Methods Between January 2013 and December 2018, a total of 50 women underwent computed tomographic angiography (CTA)-guided perforator mapping prior to abdominal flap breast reconstruction, with (n = 9) and without (n = 41) 3D-printed vascular modeling (3DVM). Models were assessed for their accuracy in identifying perforator location and source-vessel anatomy, as determined by operative findings from 18 hemi-abdomens. The margin of error (MOE) for perforator localization using 3DVM was calculated and compared with CTA-derived measurements for the same patients. Flap harvest times, outcomes, and complications for patients who were preoperatively mapped using 3DVM versus CTA alone were analyzed. Results Overall, complete concordance was observed between 3DVM and operative findings with regards to perforator number, source-vessel origin, and DIEA branching pattern. By comparison, CTA interpretation of these parameters inaccurately identified branching pattern and perforator source-vessel origin in 28 and 33% of hemi-abdomens, respectively (p = 0.045 and p = 0.02). Compared with operative measurements, the average MOE for perforator localization using 3DVM was significantly lower than that obtained from CTA alone (0.81 vs. 8.71 mm, p Conclusion The results of this study support the accuracy of 3DVM for identifying DIEA topography and perforator location. Application of this technology may translate to enhanced operative efficiency and fewer perfusion-related complications for patients undergoing abdominal free flap breast reconstruction.

Over the past several decades, technical advances in breast reconstruction have resulted in the development of flaps that are aimed at progressively decreasing abdominal wall morbidity. There is, however, ongoing controversy related to the superiority of deep inferior epigastric perforator (DIEP) flaps over muscle-sparing TRAM (MS-TRAM) flaps. Hence, the question remains unanswered as to which approach should be considered the standard of care, and more importantly, whether the rate of DIEP flap utilization should be considered a quality metric in breast reconstruction. In this review article, we examine the literature pertaining to abdominal free tissue transfer in breast reconstruction from both donor site and flap characteristics as well as the resultant complications and morbidity. The impact on the donor site remains a prevailing principle for autologous breast reconstruction; thus, must be adequately respected when classifying what is left behind following flap harvest. The most commonly used nomenclature is too simplistic. This, in turn, leads to inadequate incorporation of critical variables, such as degree of muscular preservation, fascial involvement, mesh implantation, and segmental nerve anatomy. Currently, there is insufficient evidence to support DIEP flap harvest as a quality indicator in breast reconstruction, as DIEP flap outcomes are not clearly superior when compared with MS-TRAM flaps.

Summary Introduction Groin defects with exposed complex structures are challenging to treat. Perforator flaps provide a contemporary alternative to established muscle flaps to cover all varieties of groin defects, with minimum donor site morbidity, less postoperative pain, and faster rehabilitation. In this retrospective single-center analysis, we aimed to show that pedicled perforator flaps are a valid option for groin defect reconstruction. We present three different pedicled perforator flaps and discuss the flap selection process and their distinct advantages and disadvantages. Methods A series of 54 consecutive cases of patients with groin defects were allocated into three different treatment groups. Reconstruction was performed utilizing the anterolateral thigh (ALT) flap, the pedicled posteromedial thigh (PMT) perforator flap, and the vertical deep inferior epigastric artery perforator (vDIEP) flap. Results All 54 flaps survived. Early complications included one hematoma (vDIEP) and two infections (ALT and PMT). Delayed complications occurred in three recipient-site seromas (ALT, PMT, and vDIEP), one donor-site seroma (vDIEP), and one flap dehiscence (ALT). All flaps provided stable coverage during 3–12 months of follow-up. Conclusion We propose pedicled perforator flaps to be a safe and reliable option for groin defect reconstruction. The pedicled PMT flap should be the first choice if the profunda femoris artery and its perforators are available. The ALT flap can be applied as a second choice, especially if complex groin defect with exposed vascular prosthesis reconstruction is needed because of its versatile expansion options, for example, as a chimeric flap using a portion of the vastus lateralis muscle. In cases where the profunda femoris artery is not available, the vDIEP flap should be the preferred method.

This retrospective study was conducted to compare the outcomes between the free deep inferior epigastric artery perforator (DIEP) flap and the circumflex scapular artery perforator (CSAP) flap in reconstruction of moderate-sized soft tissue defects in the foot and ankle of pediatric patients.From January 2004 to December 2016, 42 patients, ranging from 2 to 13 years old, underwent foot and ankle reconstruction, with a free DIEP flap in 21 cases and a free CSAP flap in the other 21cases.All the flaps survived. No marked differences were observed in the demographics, flap size, recipient vessels, and overall early or late complication rate (p 0.05). The CSAP group had a shorter operation time (134.3 ± 25 min vs. 202.4 ± 24.3 min, p 0.05) and flap harvest time (29.7 ± 8.1 min vs. 52.2 ± 9.8 min, p 0.05) than the DIEP group had. In long-term follow-up, the CSAP group showed a lower fat hyperplasia rate (14% vs. 52%, p 0.05) and better cosmetic outcomes than the DIEP group did (p 0.05). The functional outcomes had no marked differences (p 0.05).The DIEP flap and the CSAP flap are both good options for foot and ankle reconstruction of moderate-sized defects in pediatric patients. The CSAP flap has a shorter operation time and flap harvest time, a lower fat hyperplasia rate, and better long-term cosmetic outcomes than the DIEP flap does.

Background Adequate selection of recipient vessel to minimize recipient site morbidity is essential for a successful breast reconstruction. The authors explored the clinical use of the lateral thoracic vessels as recipient vessels in the deep inferior epigastric artery perforator (DIEP) flap breast reconstruction. Methods This study included 63 patients with breast cancer. The age of patients ranged from 26 to 67 years (43.23 ± 8.63). All patients received an immediate DIEP flap breast reconstruction using the lateral thoracic vessels as recipient vessels in the authors' department from 2014 May to 2018 September. The flap blood supply, complications, and outcomes were assessed. Results The patients were followed up for 6 to 29 months with satisfactory results. All the flaps had stable blood supply except for two cases, which had an event of partial skin necrosis and were repaired by debridement. Conclusions Lateral thoracic vessels are not only easy to explore but also have reliable blood supply, which present a safe and reliable choice for immediate DIEP flap breast reconstruction.

Background The deep inferior epigastric artery flap is an integral component of autologous breast reconstruction. The technical aspects of performing the flap have been well-established. A prior mathematical model suggested using the largest perforator and concluded that the inclusion of additional perforators may decrease resistance and increase flow, but at the downside of increased tissue trauma. Many complications may result from inadequate venous drainage of the flap and the same mathematical concepts may be applied. We attempt to give a mathematical model, based on the physics of flow and properties of circuits, to explain clinical observations regarding venous drainage of the flap and the complications that may arise. Methods We compare the different possible venous drainage systems of a perforator flap to a complex circuit with multiple resistances. Multiple venous perforators will be represented by resistances in parallel, while the deep and superficial drainage systems will be represented by a complex circuit loop. Results Drainage of the flap may be optimized through the deep drainage system if the venous perforators are of sufficient size. Inclusion of additional perforators may decrease resistance and enhance drainage. Salvage procedures may be necessary when the venous perforators are insufficient in size or when there are insufficient connections between the deep and superficial systems. Conclusion A single large sized vessel may provide adequate drainage in most DIEP flaps, while the use of multiple vessels may enhance drainage upon the encounter of smaller vessels. Salvage procedures may be needed to relieve venous congestion as the design of the venous system becomes more complicated.

Background There is a growing trend across health care to perform increasingly complex procedures in less acute settings. This shift has been fueled, in part, by enhanced recovery protocols, which have shortened hospital stays after major surgeries. We set out to determine the timing of microvascular complications after deep inferior epigastric artery perforator (DIEP) free flap breast reconstruction in a high-volume practice using continuous flap monitoring technologies. Methods The medical charts of all patients who underwent breast reconstruction with DIEP flaps over 24 consecutive months were reviewed. Postoperatively, all flaps were monitored according to a protocol that included continuous tissue oximetry with near-infrared spectroscopy. The primary end points evaluated included any unplanned return to the operating room, time to takeback, and flap loss rate. Results A total of 196 patients underwent breast reconstruction with a total of 301 DIEP flaps. Five of the flaps (1.7%) were taken back to the operating room for microvascular issues, and nine (3.0%) were taken back for nonvascular issues. Of patients who were brought back for microvascular issues, all five (100.0%) were initially identified by continuous noninvasive monitoring and taken back to the operating room within the first 14 hours (range: 1.2–13.6 hours). In the series, the flap failure rate was 0.66% (n = 2). Conclusion All of the microvascular issues were detected in the initial 23 hours after surgery, leading to prompt flap salvage. The results of this study bring into question the need for lengthy flap monitoring protocols and suggest that shorter inpatient, or even observation admissions, may be reasonable, particularly when flap monitoring protocols incorporating continuous noninvasive flap monitoring are used.

Microsurgical free tissue transfer is the most effective method for extensive reconstruction of lower limb defects. The purpose of this report is to describe our experience of using microsurgically fabricated combined linking perforator flaps for one-stage reconstruction of extensive lower limb defects. Between April 2008 and November 2016, 16 cases of extensive lower defects were reconstructed using combined linking flaps. Of the patients, 10 were males, and the mean age was 45.3 years (range = 20-76 years). The flaps used were thoracodorsal artery perforator flaps together with deep inferior epigastric artery perforator flaps or anterolateral thigh flaps. There were no total flap failures; however, 3 anterolateral thigh flaps were partially lost and required skin grafts. One wound disruption healed conservatively. Donor site healing was achieved primarily without any dehiscence. The follow-up period was 15.4 months (range = 8-24 months). The use of combined linking perforator flaps for lower limb defects is uncommon; however, in cases of extensive limb defects these flaps can salvage limbs by means of one-stage operations.

The deep inferior epigastric artery perforator (DIEP) flap is one of the most used free flaps for the reconstruction of the breast after a mastectomy. Despite careful selection of the patients and preoperative imaging, difficulties in vascularization of the flap can occur in some cases. Although multiple vascular connections (bipedicled, turbocharged, or stacked) can be made in selected cases, there can still be venous congestion before the flap is transferred. Between 2016 and 2018, 4 cases in our series of 281 patients experienced such problems. Three of 4 patients had undergone preoperative imaging of the perforators by a magnetic resonance angiography or computed tomography angiography, in which a good perforator was seen. All 4 patients had a venous problem of blood circulation in the flap intraoperatively. The flaps were left to rest to decide on its venous status. Without improvement after this period of 20 to 30 minutes, the surgeons decided to withhold the translocation of the flap to the chest wall and sutured the flap back into the donor side. The final anastomosis of the DIEP flap occurred on average 8 days after the prefabrication. The translocation of the DIEP flap to the chest in this second operation went uncomplicated in all cases. Postoperatively, all patients had adequate arterial inflow and venous outflow of the flap. There were no postoperative complications. In case a DIEP flap shows venous problems before translocation, a delay procedure can be applied. In this way, the vascularization of the flap can be improved, and the translocation of the DIEP flap in a second operation can be successfully performed.

In the setting of secondary breast reconstruction by deep inferior epigastric artery perforator (DIEP) flap, the mastectomy skin is usually deepithelialized and buried under the reconstructed breast. In this study, by virtue of tube flap technique, we hypothesize that an amount of mastectomy skin could be transferred to the apex of reconstructed breast mound for nipple reconstruction. A total of 30 female postmastectomy patients were recruited between June 2012 and August 2015. A bipedicle DIEP flap was harvested and folded upward to reconstruct the breast. An inferiorly based mastectomy flap was raised and rolled into a tube. The free end of the flap was sutured to the reconstructed breast mound to allow revascularization. After serial stages, a sufficient tissue bulk from the mastectomy flap was transferred to the apex of the breast mound and remolded into a new nipple. Reconstructed breasts and nipples survived well postoperatively. The mean nipple projection was 9.2 ± 2.7 mm at the 1-year follow-up. In total 24 patients ranked the overall nipple and breast reconstruction to be very good or good. Based on DIEP flap breast reconstruction, the staged immediate nipple reconstruction with local mastectomy tube flap could maintain a long term residual projection with aesthetically acceptable outcomes.

Background Reverse lymphatic mapping before harvesting a lymph node flap is crucial to avoid donor-site lymphedema; however, the technique is complex and unavailable in many centers. The authors introduce radioisotope-free reverse lymphatic mapping using indocyanine green and Patent Blue dye. Methods The authors conducted a prospective study in patients undergoing free vascularized groin lymph node transfer for postmastectomy upper extremity lymphedema. The day before surgery, 0.2 ml of technetium-99 was injected into the first and second web spaces of the ipsilateral foot. The following day, once the patient was anesthetized, indocyanine green was injected into the same web spaces of the same foot and Patent Blue dye was injected just proximal to the upper margin of the skin paddle of the lymph node flap. The main lymph nodes draining the limb were localized using indocyanine green lymphography and gamma probe. Results Thirty-nine patients underwent vascularized groin lymph node transfer with or without deep inferior epigastric artery perforator flap breast reconstruction. Navigation of the main lower extremity draining inguinal lymph nodes using the gamma probe and indocyanine green lymphography was identical in all patients. The blue-stained lymphatics in the skin paddle drained to the superficial proximal inguinal lymph node and were targeted for transfer. No donor-site lymphedema was reported, and lymphatic drainage of the lower extremity was preserved in all cases. Conclusions Reverse lymphatic mapping using indocyanine green lymphography provides identical results to those using technetium-99 isotope scanning. However, indocyanine green is preferable in terms of safety and reproducibility and also avoids the complexity and hazards of radioisotope mapping. Clinical question/level of evidence Therapeutic, IV.

Background: Abdominoperineal excision of the rectum (APR) remains the only potential curative treatment for very low rectal adenocarcinoma and squamous cell carcinoma of the anus. Yet, it implies a significant perineal exenteration and has set the attention on the perineal reconstruction. Aim: To present technique used in one case of APR for anal cancer, with resection of the vaginal posterior wall with large perineal defect which has called for the necessity of a flap for reconstruction Method: To cover the large perineal defect and reconstruct the posterior vaginal wall was perform a standardized and reproducible surgical technique using oblique rectus abdominis myocutaneous (ORAM) flap. The overlying skin of this flap is thick and well vascularized by both superficial branches and perforators of the superior epigastric artery and the deep inferior epigastric artery which serves as the vascular pedicle for the ORAM flap. Results: This procedure was applied in a 65-year-old woman with recurrent squamous cell carcinoma of the anus infiltrating the posterior wall of the vagina. Was performed an APR with en-bloc resection of the vaginal posterior wall in order to achieve tumor-free margins. Postoperative course was uneventful and she was discharged home at postoperative day 9. Final pathological report confirmed the oncological adequacy of the procedure (R0) and showed a rypT4N0 lesion. Conclusion: Flap reconstruction is an effective way to cover the perineal wound reducing both perineal complication rate and wound healing delay. The ORAM is particularly interesting for female whose tumors require resection and subsequent reconstruction of the posterior wall of the vagina., Graphical Abstract Myocutaneous flap of the rectus abdominis filling the perineal defect after APR.

Summary Introduction Accelerated recovery protocols have proved effective in many surgical procedures but are infrequently applied in breast reconstruction. In this study, we evaluate the impact of a structured pathway for accelerated postoperative recovery in patients undergoing microvascular breast reconstruction at a high-volume center. Methods We describe our care pathway for patients undergoing deep inferior epigastric artery perforator (DIEP) flap breast reconstruction at our center. We compared length of stay (LOS), complication rates, readmission rates, and cost of inpatient care before (pre-protocol (Pre-P)) and after (post-protocol (Post-P)) the implementation of the protocol. Results Patients in the Post-P group (n = 198) had a significant reduction in mean LOS as compared to those in the Pre-P (n = 183) group (3.6 +/− 0.85 vs. 4.7 +/−1.04 days, p = 0.006). There was no significant difference in the rates of major (Pre-P 16.9% vs. Post-P 14.7%, p = 0.71) or minor (Pre-P 21.3% vs. 17.1%, p = 0.22) postoperative complications between groups. The readmission rates were also similar (Pre-P 6.5% vs. Post-P 4.5, p = 0.69). Implementation of the protocol resulted in a significant reduction in the mean cost of in-patient care. Conclusion A simple protocol for accelerated and streamlined postoperative recovery effectively reduces LOS and patient care costs following DIEP flap breast reconstruction without compromising patient safety.

In the modern world, one-third or more of breast cancer patients still undergo uni- or bilateral mastectomy. Breast cancer patients, in general, have a good prognosis and long-term survival. Therefore, the treatment must not only focus on survival but also on the quality of life. Breast reconstruction with an autologous free deep inferior epigastric artery perforator (DIEP) flap is one of the preferred options after mastectomy. A challenging step in this procedure is the selection of a suitable perforator that provides sufficient blood supply for the flap to prevent necrosis after anastomosis. In this pilot study, the possibilities for dynamic infrared thermography (DIRT) are investigated to select the best suitable perforator. The measurements are done with external cooling in the preoperative stage to accurately predict the location of the dominant perforators. During the surgery, in the peroperative stage, measurements are done for mapping the influence of a specific perforator on the perfused areas of the abdominal flap. Perforators are sequentially dosed and opened again to map the influence of that perforator on the vascularization of the flap, visualized with the help of the thermographic camera. The acquired steady-state thermal images could help decide which parts of the abdominal flap to use for the reconstruction so that the chance of (partial) necrosis is reduced. In the postoperative stage, DIRT could visualize the arterial and or venous thrombosis before they become clinically obvious as (partial) necrosis. At present DIRT seems to be a valuable investigation for the pre-, per-, and postoperative phases of DIEP-flap reconstructions. Large, high-quality clinical studies are needed to determine its definitive role. (C) 2020 Optical Society of America

Background There is little high-quality scientific evidence identifying the best and safest methods for delayed breast reconstruction, with most previous studies retrospective in nature. The primary aim was to compare early complication rates for two different breast-reconstructive methods in radiated and non-radiated patients, using a validated scale. The secondary aim was to identify predictors for complications. Materials and methods This study represents a clinical, randomized, prospective trial ( ClinicalTrials.Gov identifier: NCT03963427), where the patients were divided into two study arms: non-radiated and radiated. In the non-radiated arm, patients were randomized to a one-stage lateral thoracodorsal flap with an implant or two-stage expander reconstruction. In the radiated arm, patients were randomized to a latissimus dorsi reconstruction combined with an implant or deep inferior epigastric artery perforator (DIEP) reconstruction. All adverse events were classified according to Clavien–Dindo and summarization of overall morbidity was performed by calculating the Comprehensive Complication Index score. The study was conducted from 2008 to 2020. Results The complication frequencies were similar for the two surgical methods within each arm. In the non-radiated arm, risk factors for any complication were any comorbidities, and in the radiated arm, factors were a high body mass index and a contralateral operation. Conclusions The usage of the Clavien-Dindo scale in reconstructive surgery is feasible, but further validation is needed. In non-radiated patients, the frequencies of short-term complications were similar for lateral thoracodorsal flap and expander reconstruction, whereas in radiated patients, they were similar for DIEP and latissimus dorsi. The complication profile of the methods varied.

Background Thoracoacromial vein (TAv) is seldomly considered as a secondary outflow recipient option when venous congestion of deep inferior epigastric artery perforator (DIEP) flap is encountered. The purpose of this study was to present a computed tomography (CT)-based anatomy and a method of approaching TAv in performing superdrainage using superficial inferior epigastric vein (SIEV) in DIEP flap breast reconstruction. Methods For CT-based anatomical study, 42 thoracoacromial vessels (TAV) of 21 patients who underwent DIEP flap breast reconstruction were analyzed. From November 2016 to May 2018, pectoralis major (PM) muscle splitting approach to TAv in the first intercostal space was applied to 7 patients who required superdrainage via SIEV. Results TAVs at mid-first intercostal space (ICS) were located 83.5 ± 9.8 mm lateral to the sternal border (H), 41.5 ± 12.9 mm below the clavicle (V), and 11.7 ± 3.2 mm deep to the outer surface of PM muscle (D). Mean oblique distances from TAV to internal mammary vessels in the 2nd and 3rd ICS were 75.7 ± 9.7 mm and 98.2 ± 10.9 mm, respectively. Seven DIEP flaps presenting intraoperative venous congestion were successfully salvaged intraoperatively with superdrainge procedure. TAvs were harvested without cutting the PM muscle in any patient. Their mean size at anastomosis was 1.61 ± 3.2 mm (range, 0.9-2.5 mm). All flaps survived without perfusion-related complications including fat necrosis. Conclusions Harvest of TAv by muscle-splitting approach is an alternative option when additional venous anastomosis using SIEV is mandated for managing venous congestion of DIEP flap.

Background The closure of massive skin defects remains challenging, particularly in children. In this report, we describe a technique to achieve primary donor site closure using the kiss deep inferior epigastric perforator (DIEP) flap for the reconstruction of large soft tissue defects located in the extremities of children. Methods From May 2011 to May 2016, a retrospective analysis was conducted on 10 pediatric patients with extensive soft tissue defects and reconstruction with double-skin paddle DIEP flap. After harvesting the flap, the skin paddle was divided into 2 separate paddles with a common vascular supply, and then the 2 paddles were sutured side by side through translating 2 paddles or rotating one of the paddles by 90 or 180 degrees, effectively doubling the width of the flap and rejoining it at the recipient site. Data on patient age, medical history, defect size, flap dimensions, recipient vessels, donor site closure, complications, and follow-up were reviewed retrospectively. Results Nine children had major soft tissue defects of the lower limb, and the remaining one had an upper limb defect. Only 1 case was complicated by partial necrosis of 1 paddle. Primary donor site closure was accomplished in all cases. The flaps were well matched on texture and contour, except that the 2 flaps were bulky at postoperative follow-up. There was no donor site breakdown, with only a slightly noticeable linear scar. Conclusion The kiss DIEP flap could be an alternative for reconstruction of large soft tissue defects of the extremities in children, with lower morbidity and improved cosmetic of the donor site.

The deep inferior epigastric artery perforator flap (DIEP) has gained widespread popularity in autologous breast reconstruction due to its natural aesthetic results and muscle-sparing design. However, donor site results regarding aesthetic outcome are often less favorable. We therefore aimed to identify crucial factors that might increase the risk for abdominal bulging and an impaired aesthetic appearance. We conducted a multicenter study evaluating all patients receiving autologous breast reconstruction using a DIEP flap between 2013 and 2017. Medical records were analyzed with special attention to flap technique, number of perforators, localization of perforator, and donor site complications. In addition, the aesthetic appearance of the abdominal donor site was evaluated by blinded clinicians at one-year follow-up. A total of 242 patients underwent DIEP flap breast reconstruction. Abdominal bulging occurred in 7%. Further subgroup analysis revealed a significant correlation between abdominal bulging and two or more perforators (P = .003), the use of lateral row perforators (P = .009), and a higher BMI (P = .002). Obesity (P = .003) and higher patient's age (P = .003) could be identified as risk factors for an undesirable appearance of the donor site. We recommend the use of a medial-row single perforator whenever possible in order to optimize donor site morbidity and decrease the risk of abdominal bulging. Proper patient selection and careful donor site closure following a standardized approach should be performed to limit the risk of aesthetically undesirable results.

Summary Lymphedema is caused by lymphatic dysfunction which leads to progressive limb enlargement. Vascularized lymph node transfer (VLNT) is a microsurgical treatment for lymphedema. Frequently used VLNT donor sites may risk donor-site lymphedema (groin) or require intraperitoneal harvest (right gastroepiploic). The purpose of this study is to describe a novel VLNT using the deep inferior epigastric artery (DIEA) nodes. Patients with lymphedema who underwent VLNT using DIEA nodes were retrospectively reviewed. The lymph nodes were harvested by taking the DIEA with the perivascular adipose near the medial and lateral row branches. Age, affected limb, body mass index (BMI), etiology of lymphedema, stage, recipient vessels, and arm measurements were assessed. Five patients underwent VLNT using DIEA nodes. All patients had upper extremity breast-cancer related lymphedema. Mean age and BMI were 55.6 years and 35.6 kg/m2, respectively. Patients underwent VLNT with DIEA to forearm (radial artery), bilevel VLNT (n=3) with DIEA to forearm or axilla with concurrent other lymph node transfer (right gastroepiploic, superficial groin), and conjoined DIEA nodes with contralateral DIEP flap breast reconstruction (to internal mammary vessels, DIEA nodes to thoracodorsal serratus branch). There were no donor site complications. Vascularized transfer of the DIEA nodes is a novel technique for treatment of lymphedema. Advantages of this technique include avoiding the risk of donor site lymphedema and convenient access during abdominally based autologous breast reconstruction. The lymph nodes can be conjoined with DIEP flap breast reconstruction.

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.

Background Given the national trends in obesity, reconstructive surgeons are faced with an increasing number of overweight and obese women interested in postmastectomy breast reconstruction. While the link between obesity and adverse postoperative outcomes is well established, few studies have explored the relationship between body mass index (BMI) and the vasculature of the anterior abdominal wall. Methods A radiographic review was conducted on female patients who underwent computed tomographic angiography (CTA) of the anterior abdominal wall. CTA studies were evaluated for perforator caliber and quantity. Patients were stratified by BMI. The relationship between BMI and the diameter and number of deep inferior epigastric artery (DIEA) perforators was analyzed using analysis of variance using Minitab software with α of 0.05. Results There were a total of 916 hemiabdomens included in this study. There was no statistically significant correlation between BMI and DIEA diameter or mean diameter of major (≥ 1 mm) DIEA perforators. There was a statistically significant negative correlation between BMI and the number of major DIEA perforators (p Conclusion Despite the increased demands of excess abdominal adiposity, DIEA perforator caliber was not correlated with BMI on CTA. The number of major DIEA perforators visualized on CTA decreased with increasing body weight may indicate a limitation of CTA for presurgical planning of abdominal free flaps in obese patients.

Background Abdominal wall morbidity following microvascular breast reconstruction continues to be an area of interest due to both functional and aesthetic concerns. Donor-site closure technique has been shown to affect bulge and hernia rates and ranges from primary closure to various uses of mesh. Few studies to date have compared types of mesh. The present study compares BARD polypropylene to bioabsorbable GORE Bio-A (polyglycolic acid/trimethylene carbonate) mesh used as a fascial underlay with primary fascial closure. Methods A retrospective review of all consecutive deep inferior epigastric artery-based microvascular breast reconstructions, including perforator and muscle-sparing flaps, performed between September 2014 and February 2017 was performed. All patients underwent primary fascial closure with mesh underlay. Risk factors for the formation of an abdominal bulge or hernia were identified by multivariate logistic regression. Results Eighty-seven patients, with 123 abdominal donor sites, were included. Heavy-weight polypropylene mesh was used for 58 donor sites, while polyglycolic acid/trimethylene carbonate mesh was used in 65 donor sites. The overall incidence of bulge or hernia was 11.4%. The bioabsorbable cohort experienced significantly more bulges/hernias than the polypropylene mesh cohort (20% vs. 1.7% by donor site). Time to diagnosis of bulge was longer for the bioabsorbable group (219 ± 107 vs. 69 days). Flap type and perforator row were not associated with bulge/hernia. The polyglycolic acid/trimethylene carbonate mesh was associated with a 13.3-fold risk of bulge/hernia (p = 0.016). Conclusion Polyglycolic acid/trimethylene carbonate mesh is not appropriate for anterior rectus fascia reinforcement following abdominal tissue transfer.

Background The deep inferior epigastric artery perforator (DIEP) flap is currently the most widely used method for autologous microsurgical breast reconstruction. There are mixed data in the literature regarding the impact of previous abdominal surgery on DIEP flap success in breast reconstruction. With this study, we take a closer look at the effect of prior abdominal surgery on DIEP flap and donor-site complications, with a particular focus on the different types of incisions and their influence on surgical outcomes. Methods A retrospective cohort study was conducted over a 6-year period. Five hundred forty-four consecutive DIEP flaps were divided into a control group (321 flaps) without previous abdominal surgery and an incision group (223 flaps) with previous abdominal surgery. A comparison between both groups was made in terms of flap and donor-site complications followed by a subgroup analysis based on single types of abdominal incisions. Results There were no significant differences between both groups in terms of age, body mass index, flap weight, smoking history, prior radiotherapy, diabetes, and coagulopathy (P > 0.05). The most common incision was low transverse incision (n = 116) followed by laparoscopy port (n = 103) and midline (n = 46) incisions. We found no significant differences between the control group and incision group in terms of flap complications. Subgroup analysis revealed that none of the 3 types of incision increase the flap or donor-site complications. Smoking and flap weight were the only 2 independent predictors for donor-site complications. Conclusions The results from this large series of consecutive DIEP flaps from our institution confirm that autologous breast reconstruction with DIEP flap can be safely performed in patients who have had previous abdominal surgeries; however, counseling patients about smoking is critical to avoid potential donor-site complications.

Background The creation of skin flaps based on small perforator vessels is an increasingly popular procedure nowadays; the optimization of their blood supply enhances surgical success. This study evaluates the effects on the flowmetries of 7 days' negative pressure application on the skin surface overlying the muscle fascia emergence of periumbilical perforators of the deep inferior epigastric artery (DIEA). Methods Ten volunteer participants were enrolled. In each subject, one periumbilical perforator of the DIEA was identified on each side of the abdomen using an eco-color-Doppler. One of them was used as the control group, while the other (the study group) underwent 80 mm Hg negative pressure for 7 days. The flowmetries of both perforators were measured before and after the application of negative pressure wound therapy. Results After the application of negative pressure, randomly applied on the skin surface over one of the two selected periumbilical perforators, an increase in the flowmetries was observed in both groups of perforators (2.74 cm/s; p Conclusion The application of negative pressure system on the skin surface over the muscle fascia emergence of the selected periumbilical perforators showed an increase in flowmetry. Although this is a preliminary study, this simple and economical procedure before surgery could be usefully employed to increase the rate of success in microsurgical procedures.

Management of the umbilicus is a common dilemma at the time of abdominoplasty and abdominal wall reconstruction. It is not uncommon for underlying pathologies, such as hernias and surgical scars, to result in a disfigured or obliterated native umbilicus or make the blood supply to the umbilical stalk unreliable. In these scenarios, the umbilicus is often sacrificed. Staged neoumbilical reconstruction may be offered and typically utilizes a small skin flap and full-thickness skin graft (Ann Plast Surg 2009;63:358-360). Our technique, in contrast, permits reconstruction of the neoumbilicus in the immediate setting utilizing normally discarded skin with a robust blood supply from a deep inferior epigastric artery perforator. In this series of 13 consecutive neoumbilicoplasties, the pedicled deep inferior epigastric artery perforator island flap provided reliable results and favorable aesthetic outcomes.

Background: The lumbar artery perforator flap is an alternative flap in breast reconstruction for those patients who are not eligible for a deep inferior epigastric artery perforator (DIEAP) flap. Shaping of this flap is easier compared with other flaps because of the quality of the lumbar fat and the gluteal extension. Methods: Between October of 2010 and June of 2017, a total of 100 lumbar artery perforator free flap breast reconstructions were performed in 72 patients. Patient demographics, indications, flap specifics, and complications were reviewed retrospectively. Results: Twenty-eight bilateral and 44 unilateral breast reconstructions with a lumbar artery perforator flap were performed. Mean patient age was 48 years, and the average body mass index was 23.11 kg/m(2). The authors report 43 preventive mastectomies for elevated cancer risk with subsequent immediate reconstruction, 34 secondary reconstructions, and 14 tertiary reconstructions. Mean operative time was 7 hours 4 minutes, including the mastectomy in primary cases. Mean flap weight was 499 g (range, 77 to 1216 g) and mean follow-up time was 30 months. The revision rate was 22 percent and nine flaps were lost. Conclusions: The lumbar artery perforator flap is a valuable alternative to the DIEAP flap in breast reconstructive surgery. It is an excellent flap for BRCA-positive patients who are typically young and have limited excess tissue at the conventional donor sites. Despite higher revision rates compared with the DIEAP flap, the lumbar flap is superior in mimicking the shape and feel of native breast tissue. Scarring at the donor site remains a sore point but can be easily treated and used to an advantage to contour the flanks.

Summary Introduction Breast reconstruction techniques are multiple and they should be chosen in order to improve women's satisfaction and well-being, thus obtaining a personalized treatment. This report's major purpose was to study, through the Breast-Q questionnaire, how the functional and aesthetic outcomes, as well as the complications, of the main autologous breast reconstruction techniques, can affect patients quality of life and well-being at long-term. The secondary purpose was to analyse, thus to identify, the independent factors characterizing the different reconstructive techniques, which may affect patients’ satisfaction. Methods Women who underwent autologous breast reconstruction through deep inferior epigastric artery perforator or Latissimus dorsi muscle flap from May 2006 to May 2013 were included. The assessment was based on the Breast-Q reconstruction questionnaire. All times of post-mastectomy reconstruction were concerned: immediate, delayed, after previous procedure failure or conversion to another reconstructive technique due to the patient's dissatisfaction. Results A total of 98 patients were included. Concerning patients satisfaction, the breast-Q score is highest in patients who underwent immediate breast reconstruction, while scores after delayed breast reconstruction, previous surgery failure or conversion to another technique are generally equivalent. Higher scores have been observed in patients who underwent reconstruction through autologous Latissimus dorsi compared to Latissimus dorsi with prosthetic implant reconstruction. Conclusion The authors identified factors of higher patients’ satisfaction, like absence of major complication and advanced patient's age, in order to personalize the surgical planning according to the patient's priorities.

BACKGROUND While complications of deep inferior epigastric artery perforator flaps are known and well documented, a thorough literature review revealed no other reports of a patient developing a chyle leak following the use of the internal mammary vessels for recipient vessels in autologous breast reconstruction. CASE A 55-year-old woman underwent free autologous breast reconstruction. She developed a chyle leak during the postoperative period. This was verified through a computed tomography scan and fluid analysis demonstrating a high triglyceride count and the presence of chylomicrons. The leak resolved with conservative measures including compression and a low-fat, high-protein diet. DISCUSSION The presence of chyle leak following dissection of the internal mammary vessels is a unique complication of autologous breast reconstruction. There have been reports of lymph leaks following mastectomy, but these are mostly reported in the axilla. A history of radiation to the contralateral breast and aberrant anatomy may have contributed to the complication. Treatment of chyle leaks ranges from conservative management to the use of total parenteral nutrition and somatostatin analogs to surgical intervention. CONCLUSION While altering practice patterns based on a single case is not usually suggested, this complication does intimate that dealing with lymphatic vessels and lymph nodes in the chest should be done deliberately to prevent lymphatic leaks.

The deep inferior epigastric perforator (DIEP) flap is a mainstay of autologous breast reconstruction. The da Vinci robot has recently been adapted for an increasing number of reconstructive surgeries. The literature has yet to describe its use for the intra-abdominal harvest of the deep inferior epigastric vessels (DIEV) during DIEP flap breast reconstruction. We show the use of the da Vinci robotic surgical system for the intra-abdominal dissection of DIEV during delayed breast reconstruction with a DIEP flap in a 51-year-old female who had undergone a right modified radical mastectomy. After dissecting the flap from the anterior abdominal wall leaving only the targeted perforating vessels intact, a 1.5 cm fascial incision was made adjacent to the perforator and the vessels were dissected to below the level of the fascia. The intra-abdominal robotic-assisted dissection of the DIEV up to the perforator was then completed. The DIEV were divided at their origin using the robot and the flap removed from the abdomen for subsequent reconstruction. This technique enabled improved precision of flap harvest while also decreasing the donor-site morbidity by minimizing the incision length of the anterior rectus sheath. The patient had an uneventful postoperative course and, at 9-month follow-up, exhibited no evidence of flap or donor-site complications, specifically hernia or bulge. This novel approach for the harvest of a DIEP flap introduces an alternative technique to the conventional DIEP flap procedure in the appropriate patient population. Risks inherent to this technique as well as additional costs must be considered.

Autologous breast reconstruction can be challenging in mastectomy patients who are not eligible for a deep inferior epigastric artery perforator flap reconstruction. Depending on body habitus, alternative donor sites for free flap transfer can be found on the back, the thighs, and in the gluteal area. These alternative flaps can demand a higher level of expertise, which should be mastered by the modern day reconstructive microsurgeon. The flap choice should be tailored individually to each patient and should not be limited by the difficulty of the surgery.

BACKGROUND: The deep inferior epigastric artery perforator (DIEP) flap is one of the most common techniques for breast reconstruction. Body mass index (BMI) is considered as an important predictor of donor site healing complications such as wound dehiscence. The use of computed tomography (CT) proved to be a precise and objective method to assess visceral adipose tissue. It remains unclear whether quantification of visceral fat provides more accurate predictions of abdominal wound healing complications than BMI.PATIENTS AND METHODS: A total of 97 patients with DIEP flap were retrospectively evaluated. Patients' abdominal visceral fat (AVF) was quantified on CT angiography (CTA). The patients were postoperatively assessed for abdominal wound healing complications. We analyzed for the correlations between AVF, BMI, and dehiscence and established a logistic regression model to assess the potential high-profile predictors in anatomic and patient characteristics such as weight, smoking, and diabetes.RESULTS: We included 97 patients, and of them, 24 patients (24.7%) had some degree of abdominal dehiscence. No significant differences were observed between the dehiscence group and the non-dehiscence group, except for smoking (p = 0.002). We found a significant correlation between AVF and BMI (R = 0.282, p = 0.005), but neither was significant in predicting donor site dehiscence. Smoking greatly increased the likelihood of developing wound dehiscence (OR = 11.4, p = CONCLUSIONS: AVF and BMI were not significant predictors of abdominal wound healing complications after DIEP flap reconstruction. This study established active smoking (OR = 11.4, p =

Patient: Female, 82 Final Diagnosis: Giant basal cell carcinoma Symptoms: Anemia Medication: — Clinical Procedure: — Specialty: Plastic Surgery Objective: Rare disease Background: Basal cell carcinoma (BCC) greater than 5 cm in diameter is called giant basal cell carcinoma (GBCC), or super giant basal cell carcinoma if it has a diameter larger than 20 cm. Giant BCC only accounts for 0.5% of BCCs and super giant BCC is exceedingly rare. On account of their rarity, there are no established guidelines for GBCC treatment. Case Report: We describe a peculiar case of an 82-year-old woman with a GBCC carcinoma of the lower abdominal wall. The tumor was surgically removed with ipsilateral inguinal lymph nodes and the abdominal wall was reconstructed immediately with a pedicled deep inferior epigastric artery perforator (DIEP) flap. Conclusions: Treatment of giant basal cell carcinoma is often difficult, especially in elderly patients with poor general health and multiple pathologies. The pedicled DIEP flap is rotated to cover the loss of substance without tension, and it is easy to harvest and transfer. This flap allowed a good result without local or systemic complication. We present this report as a reminder of the occasional occurrence of extremely aggressive BCCs. We believe that, especially for rare tumors like these, it is very useful for the entire scientific community to publish these cases and the therapeutic strategies used to treat them.