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| 2. |
- Acosta, Rafael, et al.
(author)
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Performing two DIEP flaps in a working day : an achievable and reproducible practice
- 2010
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In: Journal of Plastic, Reconstructive and Aesthetic Surgery. - : Elsevier BV. - 1748-6815. ; 63:4, s. 648-654
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Journal article (peer-reviewed)abstract
- 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 59 min 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.
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| 4. |
- Audolfsson, Thorir, et al.
(author)
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A Reliable and Aesthetic Technique for Cephalic Vein Harvest in DIEP Flap Surgery
- 2009
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In: Journal of reconstructive microsurgery. - : Georg Thieme Verlag KG. - 0743-684X .- 1098-8947. ; 25:5, s. 319-321
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Journal article (peer-reviewed)abstract
- The need for a secondary source of venous drainage in deep inferior epigastric artery perforator flaps is common, with the cephalic vein Commonly utilized as an alternative venous recipient vessel. In using the cephalic vein, previous studies have described the deltopectoral groove or the infraclavicular fossa as the site for harvest. We describe the use of an anterior axillary skin crease, which can improve aesthetic outcome, reduce the time needed for harvest, enable a greater length of vein to be transposed, and minimize surgical insult to the upper breast/chest wall. An anterior axillary-line skin fold can be used as the site for cephalic vein harvest, and using the methodology described, the technique can be fast and highly reliable and result in a final scar that is barely visible.
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| 5. |
- Chubb, Daniel, et al.
(author)
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The Efficacy of Clinical Assessment in the Postoperative Monitoring of Free Flaps : A Review of 1140 Consecutive Cases
- 2010
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In: Plastic and reconstructive surgery (1963). - 0032-1052 .- 1529-4242. ; 125:4, s. 1157-1166
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Journal article (peer-reviewed)abstract
- Background: Effective postoperative monitoring of the vascular pedicle to a free flap can potentiate rapid return to the operating room in the setting of compromise, allowing for the potential to salvage the flap. The only ubiquitous method for postoperative monitoring of free flaps is clinical bedside monitoring, but although the use of clinical monitoring may be inferred in large reported series of free flaps, there has been little discussed in the literature of specific clinical outcome measures. Methods: The authors present their experience with 1140 consecutive cases of free tissue transfer and the use of clinical monitoring as a sole method of monitoring, and subgroup analysis of different recipient sites. Results: There were 94 take-backs, four of which had no pedicle compromise (false-positives) and there were four false-negatives. The overall flap salvage rate was 62.8 percent and the false-positive rate was 0.4 percent. Subgroup analyses demonstrated statistically significant differences between recipient sites for the false-positive rates: fewer false-positives with breast reconstruction cases (p < 0.05) and significantly more false-positives in the extremity group (p < 0.05). There was an improved flap salvage rate in cases of venous compromise compared with arterial compromise (69 percent versus 51 percent, p = 0.015). Conclusions: This largest reported series to date provides an outcome-based analysis of postoperative monitoring for free flaps, providing a benchmark standard against which adjunctive monitoring techniques can be compared. Future studies need to be assessed in the context of individual recipient sites, with significant differences in monitoring outcomes between sites.
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| 6. |
- Enajat, Morteza, et al.
(author)
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A single center comparison of one versus two venous anastomoses in 564 consecutive diep flaps : Investigating the effect on venous congestion and flap survival
- 2010
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In: Microsurgery. - : Wiley. - 0738-1085 .- 1098-2752. ; 30:3, s. 185-191
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Journal article (peer-reviewed)abstract
- Background: Venous complications have been reported as the more frequently encountered vascular complications seen in the transfer of deep inferior epigastric artery (DIEA) perforator (DIEP) flaps, with a variety of techniques described for augmenting the venous drainage of these flaps to minimize venous congestion. The benefits of such techniques have not been shown to be of clinical benefit on a large scale due to the small number of cases in published series. Methods: A retrospective study of 564 consecutive DIEP flaps at a single institution was undertaken, comparing the prospective use of one venous anastomosis (273 cases) to two anastomoses (291 cases). The secondary donor vein comprised a second DIEA venae commitante in 7.9% of cases and a superficial inferior epigastric vein (SIEV) in 92.1%. Clinical outcomes were assessed, in particular rates of venous congestion. Results: The use of two venous anastomoses resulted in a significant reduction in the number of cases of venous congestion to zero (0 vs. 7, P = 0.006). All other outcomes were similar between groups. Notably, the use of a secondary vein did not result in any significant increase in operative time (385 minutes vs. 383 minutes, P = 0.57). Conclusions: The use of a secondary vein in the drainage of a DIEP flap can significantly reduce the incidence of venous congestion, with no detriment to complication rates. Consideration of incorporating both the superficial and deep venous systems is an approach that may further improve the venous drainage of the flap.
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| 7. |
- Enajat, Morteza, et al.
(author)
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How long are fasciocutaneous flaps dependant on their vascular pedicle : A unique case of SIEA flap survival
- 2010
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In: Journal of Plastic, Reconstructive and Aesthetic Surgery. - : Elsevier BV. - 1748-6815. ; 63:4, s. E347-E350
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Journal article (peer-reviewed)abstract
- Background: While it has long been held that muscle flaps maintain their dependency on their vascular pedicle for the long term, fasciocutaneous flaps have been less well investigated. Recent studies of the deep inferior epigastric artery perforator (DIEP) flap have suggested that these flaps may maintain long term dependence on their vascular pedicles for survival. There is no literature concerning these effects in the superficial inferior epigastric artery (SIEA) flap. Case report: We describe a unique case in which the pedicle of a superficial inferior epigastric artery (SIEA) flap for breast reconstruction was avulsed 11 days postoperatively, with the flap surviving on its inferior wound edge alone. Conclusion: Fasciocutaneous flaps may lose dependency on their vascular pedicles in the short term following transfer, developing alternative pathways for vascular supply and ultimately survival. A conservative approach early in the course of flap compromise due to perforator ligation or avulsion, in cases where immediate re-anastomosis may not be feasible, is thus supported.
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| 8. |
- Enajat, Morteza, et al.
(author)
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The deep inferior epigastric artery perforator flap for autologous reconstruction of large partial mastectomy defects
- 2011
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In: Microsurgery. - : Wiley. - 0738-1085 .- 1098-2752. ; 31:1, s. 12-17
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Journal article (peer-reviewed)abstract
- Background: Breast conservation surgery in the treatment of early stage breast cancer has become increasingly utilized as a means to avoiding mastectomy. While partial mastectomy defects (PMDs) may often be cosmetically acceptable, some cases warrant consideration of reconstructive options, and while several reconstructive options have been described in this role, a series of deep inferior epigastric perforator (DIEP) flaps has not been reported to date. Methods: A cohort of 18 patients undergoing PMD reconstruction with a DIEP flap were included. Patient-specific data, operation details, cosmetic results, and complication rates were assessed. Oncologic outcomes, in particular recurrence rates, were also evaluated. Results: In our series there were no cases of partial or total flap necrosis, and overall complications were low. There were two cases of wound infection (both had undergone radiotherapy), managed conservatively, and one case of reoperation due to hematoma. There were no cancer recurrences or effect on oncologic management. Cosmetic outcome was rated as high by both patients and surgeon. The results were thus comparable with other reconstructive options. Conclusion: Although autologous reconstruction has an established complication rate, our results suggest that the DIEP flap may be of considerable value for delayed reconstruction of selected larger partial mastectomy defects.
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