scholarly journals Lessons Learned from 30 Years of Transverse Myocutaneous Gracilis Flap Breast Reconstruction: Historical Appraisal and Review of the Present Literature and 300 Cases

2021 ◽  
Vol 10 (16) ◽  
pp. 3629
Author(s):  
Laurenz Weitgasser ◽  
Maximilian Mahrhofer ◽  
Karl Schwaiger ◽  
Kathrin Bachleitner ◽  
Elisabeth Russe ◽  
...  
Keyword(s):  
Breast Reconstruction ◽  
Donor Site ◽  
Free Flaps ◽  
Lessons Learned ◽  
Diep Flap ◽  
Patient Demographics ◽  
Pedicle Length ◽  
History Of ◽  
Deep Inferior Epigastric Perforator ◽  
Low Bmi

Background: Happy 30th birthday to the transverse myocutaneous gracilis (TMG) flap. Since 1991 the TMG flap has been used to reconstruct a wide variety of defects and became a workhorse flap and reliable alternative to the deep inferior epigastric perforator (DIEP) flap in many breast reconstruction services worldwide. This manuscript sheds light on the history and success of the TMG flap by critically reviewing the present literature and a series of 300 patients receiving a breast reconstruction. Patients and Methods: The present literature and history of the TMG flap was reviewed and a retrospective double center cohort study of 300 free TMG free flaps for autologous breast reconstruction was conducted. Patient demographics, perioperative data, and post-operative complications were recorded and compared with literature findings. Results: Mean flap weight was 320 g. Mean pedicle length was 70 mm. Complications included 19 (6.3%) flap loss. 10 patients (3.3%) had postoperative cellulitis and 28 (9.3%) wound healing disturbance of the donor site. Conclusion: Recipient and donor site complications were comparable to other free flaps used for breast reconstruction. A low BMI or the lack of an abdominal based donor site do not represent a limitation for breast reconstruction and can be overcome using the TMG flap.

scholarly journals Refractory Donor-Site Seroma Following DIEP Breast Reconstruction

2020 ◽  
Vol 6 ◽  
pp. 2513826X1989883
Author(s):  
Trina V. Stephens ◽  
Nancy Van Laeken ◽  
Sheina A. Macadam
Keyword(s):  
Literature Review ◽  
Breast Reconstruction ◽  
Donor Site ◽  
Diep Flap ◽  
First Line ◽  
Percutaneous Aspiration ◽  
Autologous Breast Reconstruction ◽  
History Of ◽  
Deep Inferior Epigastric Perforator ◽  
Latissimus Dorsi Flaps

Donor-site seroma formation is a complication of autologous breast reconstruction reported most commonly with the use of latissimus dorsi flaps. First-line treatment is percutaneous aspiration which leads to resolution in the majority of cases. Those that persist may progress to a chronic, refractory seroma, which can prove challenging in terms of treatment. The aim of this article is to provide an updated literature review of interventions for chronic donor-site seroma and present the case of a 65-year-old female with a recalcitrant abdominal seroma following deep inferior epigastric perforator (DIEP) flap breast reconstruction. Literature review revealed a single article that reported 2 cases of persistent donor-site seroma after DIEP flap breast reconstruction. The patient presented here underwent repeat aspiration, drain placement, and multiple surgical procedures to achieve resolution. In total, the post-reconstruction seroma history of the patient extended over approximately 14 months. We conclude with evidence-based suggestions for chronic, donor-site seroma prevention and treatment.

Alternative flaps for microsurgical breast reconstruction

2021 ◽  
pp. 1107-1114
Author(s):  
Hinne A. Rakhorst
Keyword(s):  
Breast Reconstruction ◽  
Standard Care ◽  
Donor Site ◽  
Perforator Flap ◽  
Donor Site Morbidity ◽  
The Body ◽  
Diep Flap ◽  
Deep Inferior Epigastric Perforator ◽  
Muscle Sparing ◽  
Breast Reconstructive Surgery

Microsurgery in general has made dramatic improvements over the past decades. This applies to microsurgery in general and to breast reconstructive surgery especially. The demand for autologous breast reconstruction has risen. Since the introduction of the free transverse rectus abdominis myocutaneous (TRAM) flaps, through the muscle-sparing TRAM, flaps designs have evolved into the current gold standard, the deep inferior epigastric perforator (DIEP) flap. From experiences and increasing numbers of flap procedures performed by surgeons, techniques became more familiar and part of standard care. These factors gave rise to the development of a growing number of areas of the body where tissues of interest can be harvested using perforator flap-based techniques. This chapter discusses the most common as well as the ‘rising stars’ in terms of flaps to be used as alternative flaps to the DIEP flap for breast reconstruction. It discusses practical issues on dissection as well as donor site morbidity.

Unilateral Autologous Breast Reconstruction with Bi-pedicled, Conjoined Deep Inferior Epigastric Perforator Flaps

2018 ◽  
Vol 35 (02) ◽  
pp. 145-155 ◽  
Author(s):  
Akhil Seth ◽  
Pieter Koolen ◽  
Steven Sultan ◽  
Bernard Lee ◽  
Heather Erhard ◽  
...  
Keyword(s):  
Soft Tissue ◽  
Breast Reconstruction ◽  
Donor Site ◽  
Side Branch ◽  
Diep Flap ◽  
Autologous Breast Reconstruction ◽  
Pedicled Flaps ◽  
Skin Envelope ◽  
The Status ◽  
Deep Inferior Epigastric Perforator

Background The abdomen remains the most popular and reliable donor site for autologous breast reconstruction. Some patients, however, lack sufficient tissue to recreate an aesthetic breast mound using a single-pedicle, deep inferior epigastric perforator (DIEP) flap, particularly when matching a contralateral native breast. The amount of abdominal skin and/or soft tissue reliably supplied by one vascular pedicle is frequently insufficient to adequately restore the breast skin envelope and “footprint.” This study summarizes our experience with using bipedicled DIEP flaps to improve the aesthetic results of unilateral breast reconstruction in such patients. Methods Consecutive patients undergoing unilateral breast reconstruction with bi-pedicled, conjoined DIEP flaps over a 4-year period were retrospectively reviewed. Primary and secondary flap microvascular anastomoses were performed to the antegrade internal mammary (IM) vessels and to either the retrograde IM vessels or a primary DIEP pedicle side branch, respectively. Clinical characteristics and outcomes were recorded. Results Sixty-three patients underwent immediate (n = 29) or delayed (n = 34) reconstruction, with age and body mass index of 54.1 ± 8.4 years and 26.6 ± 4.7, respectively. Mean follow-up was 14.1 months. Twenty-eight (44.4%) patients received prereconstruction radiation therapy. All patients had preoperative abdominal imaging, including 57 (90.5%) using magnetic resonance angiography. There were no flap losses with three operative interventions for flap salvage. Conclusion Unilateral breast reconstruction with bipedicled, conjoined DIEP flaps is safe and reliable. These procedures can be performed with a complication profile similar to single-pedicle DIEP flaps. The additional skin and soft tissue available with bi-pedicled flaps allows for greater flexibility in matching the shape and projection of a woman's contralateral breast, and in some cases is necessary to achieve an aesthetically acceptable reconstruction. With growing expectations among breast reconstruction patients, conjoined bi-pedicled flaps represent a tool for meeting their reconstructive needs and exceeding the status quo for aesthetic outcomes.

Clinical Decision Making Using CTA in Conjoined, Bipedicled DIEP and SIEA for Unilateral Breast Reconstruction

2019 ◽  
Vol 36 (04) ◽  
pp. 241-246 ◽  
Author(s):  
Min-Jeong Cho ◽  
Nicholas T. Haddock ◽  
Sumeet S. Teotia
Keyword(s):  
Breast Reconstruction ◽  
Clinical Decision Making ◽  
Free Flaps ◽  
Clinical Decision ◽  
Computed Tomographic Angiography ◽  
Computed Tomographic ◽  
Patient Demographics ◽  
Epigastric Artery ◽  
Deep Inferior Epigastric Perforator ◽  
Tomographic Angiography

Abstract Background Using a hemi-abdominal flap for unilateral breast reconstruction in patients may not be ideal due to paucity of abdominal tissue, presence of a lower abdominal midline scar, or a larger and/or ptotic contralateral native breast. Several algorithms exist to make these flaps successful, but all of them require an anastomosis sequence ultimately. In this study, we present our experience with the use of imaging to predict flap dominance and anastomosis sequence to make them consistently successful. Methods Seventy-five consecutive conjoined, bipedicled abdominal composite free flaps for unilateral breast reconstruction were performed. Preoperative computed tomographic angiography (CTA) was obtained to depict the pattern of perforators, flap dominance, and feasibility for intraflap anastomosis. Patient demographics, type/weights of flaps, number of anastomoses, location of perforators, length/type of pedicles, and flap-related complications were reviewed. Results Seventy-five patients underwent composite deep inferior epigastric perforator (DIEP) and/or superficial inferior epigastric artery (SIEA) flaps. There were 62 DIEP-DIEP flaps, 11 DIEP-SIEA flaps, and two SIEA-SIEA flaps. The mean age was 57 years with an average body mass index of 27 kg/m2 and flap weight of 1,054 g. Thirty-one patients underwent intraflap (41%) and 44 patients underwent crania/caudal anastomoses (59%). In comparison to bilateral DIEPs, the total number of perforators was significantly lower (2.9 vs. 3.8), and fat necrosis rate was lower (2.7 vs. 14.4%) as well. Conclusion Guided by preoperative CTA imaging, we recommend the consistent use of these conjoined, bipedicled hemi-abdominal flaps for unilateral breast reconstruction, primarily those with delayed reconstruction and radiation deficits. Preoperative CTA imaging is crucial in directing perforator dissection to maximize overlapping perfusion zones and guide in performing anastomoses.

scholarly journals Stacked Deep Inferior Epigastric Perforator Free Flaps with Immediate Implant Placement for Unilateral Breast Reconstruction

2017 ◽  
Vol 02 (01) ◽  
pp. e72-e74
Author(s):  
Keith Hood ◽  
Nishant Kumar ◽  
Stephane Braun ◽  
Kent Higdon
Keyword(s):  
Breast Reconstruction ◽  
Capsular Contracture ◽  
Free Flaps ◽  
Left Breast ◽  
Diep Flap ◽  
Augmentation Mammoplasty ◽  
Aesthetic Result ◽  
Implant Placement ◽  
Deep Inferior Epigastric Perforator ◽  
Immediate Implant

Background Autologous flaps can be used in combination with prosthesis in postmastectomy breast reconstruction. The deep inferior epigastric perforator (DIEP) flap is considered the preferred choice among autologous tissue transfer techniques. In patients with a breast volume asymmetry, there are several options for attaining an optimal reconstructive and aesthetic result. Methods This report presents a patient who underwent a combination of reconstructive techniques to achieve volumetric symmetry. Results The patient had a previous bilateral augmentation mammoplasty, was then treated for left breast carcinoma with a lumpectomy and radiation, and since that time had a recalcitrant left capsular contracture despite multiple operative interventions. The patient ultimately chose to have autologous left breast reconstruction and a stacked DIEP flap with simultaneous implant placement was performed. Conclusion In cases of significant volumetric asymmetry, a stacked DIEP flap in combination with a prosthesis is a novel and safe solution.

The PAP Flap Breast Reconstruction: A Practical Option for Slim Patients

2021 ◽  
Author(s):  
Taehee Jo ◽  
Dong Nyeok Jeon ◽  
Hyun Ho Han
Keyword(s):  
Donor Site ◽  
Wound Dehiscence ◽  
Diep Flap ◽  
Separate Analysis ◽  
Flap Reconstruction ◽  
Average Body Mass Index ◽  
Deep Inferior Epigastric Perforator ◽  
Average Body Mass ◽  
Artery Perforator ◽  
Average Body

Abstract Background The posterior thigh-based profunda artery perforator (PAP) flap has been an emerging option as a secondary choice in breast reconstructions. However, whether a PAP flap could consistently serve as the secondary option in slim patients has not been investigated. Methods Records of immediate unilateral breast reconstructions performed from May 2017 to June 2019 were reviewed. PAP flap breast reconstructions were compared with standard deep inferior epigastric perforator (DIEP) flap breast reconstructions, and were grouped into single or stacked PAP flaps for further analysis. Results Overall, 43 PAP flaps were performed to reconstruct 32 breasts. Eleven patients underwent stacked PAP flap reconstruction, while 17 patients underwent 21 single PAP flap reconstruction. The average body mass index (BMI) of the patients was 22.2 ± 0.5 kg/m2. The results were as follows: no total loss, one case of venous congestion (2.3%), two donor site wound dehiscence cases (4.7%), and one case of fat necrosis from partial flap loss (2.3%). When compared with 192 DIEP flap reconstructions, the final DIEP flap supplied 98.1 ± 1.7% of mastectomy weight, while the final PAP flap supplied 114.1 ± 6.2% of mastectomy weight (p < 0.005), demonstrating that PAP flaps can successfully supply final reconstruction volume. In a separate analysis, single PAP flaps successfully supplied 104.2% (84.2-144.4%) of mastectomy weights, while stacked PAP flaps supplied 103.7% (98.8-115.2%) of mastectomy weights. Conclusion In our series of PAP flap reconstructions performed in low-to-normal BMI patients, we found that PAP flaps, as single or stacked flaps, provide sufficient volume to reconstruct mastectomy defects.

Breast Reconstruction After Resection of Bilateral Giant Phyllodes Tumors: Two Separate Deep Inferior Epigastric Perforator Flaps From One Donor Site

2020 ◽  
Vol 20 (2) ◽  
pp. e188-e191
Author(s):  
Chin-Wen Tu ◽  
Chien-Liang Fang ◽  
Chong-Bin Tsai ◽  
Chin-Hao Hsu ◽  
Chih-Hsuan Changchien ◽  
...  
Keyword(s):  
Breast Reconstruction ◽  
Donor Site ◽  
Perforator Flaps ◽  
Phyllodes Tumors ◽  
Deep Inferior Epigastric Perforator

Observations from Implementation of the ERAS Protocol after DIEP Flap Breast Reconstruction

2021 ◽  
Author(s):  
Nicholas T. Haddock ◽  
Ricardo Garza ◽  
Carolyn E. Boyle ◽  
Sumeet S. Teotia
Keyword(s):  
Breast Reconstruction ◽  
Patient Outcomes ◽  
Enhanced Recovery ◽  
Enhanced Recovery After Surgery ◽  
Compliance Rate ◽  
Fluid Management ◽  
Control Group ◽  
Diep Flap ◽  
Deep Inferior Epigastric Perforator ◽  
Eras Protocol

Abstract Background The Enhanced Recovery After Surgery (ERAS) protocol is a multivariate intervention requiring the help of several departments, including anesthesia, nursing, and surgery. This study seeks to observe ERAS compliance rates and obstacles for its implementation at a single academic institution. Methods This is a retrospective study looking at patients who underwent deep inferior epigastric perforator (DIEP) flap breast reconstruction from January 2016 to September 2019. The ERAS protocol was implemented on select patients early 2017, with patients from 2016 acting as a control. Thirteen points from the protocol were identified and gathered from the patient's electronic medical record (EMR) to evaluate compliance. Results Two hundred and six patients were eligible for the study, with 67 on the control group. An average of 6.97 components were met in the pre-ERAS group. This number rose to 8.33 by the end of 2017. Compliance peaked with 10.53 components met at the beginning of 2019. The interventions most responsible for this increase were administration of preoperative medications, goal-oriented intraoperative fluid management, and administration of scheduled gabapentin postoperatively. The least met criterion was intraoperative ketamine goal of >0.2 mg/kg/h, with a maximum compliance rate of 8.69% of the time. Conclusion The introduction of new protocols can take over a year for full implementation. This is especially true for protocols as complex as an ERAS pathway. Even after years of consistent use, compliance gaps remain. Staff-, patient-, or resource-related issues are responsible for these discrepancies. It is important to identify these issues to address them and optimize patient outcomes.

The Influence of Closing the Abdominal Donor-Site Superficial Fascial System in Deep Inferior Epigastric Perforator Flap Breast Reconstruction

2021 ◽  
Vol 148 (3) ◽  
pp. 357e-364e
Author(s):  
Ariel C. Johnson ◽  
Becky B. T. King ◽  
Salih Colakoglu ◽  
Jerry H. Yang ◽  
Tae W. Chong ◽  
...  
Keyword(s):  
Breast Reconstruction ◽  
Donor Site ◽  
Perforator Flap ◽  
Deep Inferior Epigastric Perforator ◽  
Superficial Fascial System
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