For this study, the authors evaluated early psychosocial adjustments and health-related quality-of-life changes after breast reconstruction.All consecutive patients who underwent breast reconstruction between June 2009 and November 2010 were asked to complete the BREAST-Q, Hospital Anxiety and Depression Scale (HADS), and Impact of Event Scale (IES) questionnaires before surgery and at 3 weeks and 3 months after surgery. A repeated-measures design was used to compare scores between baseline and postoperative time points.Fifty-one of 55 women completed the questionnaires (response rate, 93%). BREAST-Q subscale scores (breast, sexual well being, and psychosocial well being) improved significantly (P <.05) postoperatively. The other subscale scores related to physical well being of the chest and abdomen dropped significantly 3 weeks after reconstruction; and, by 3 months after reconstruction, both scores improved significantly (P <.05). Large effect sizes for improvements in satisfaction, psychosocial well being, and sexual well being were observed (1.88, 1.2, and 1.31, respectively); whereas deterioration in the effect size for abdominal donor site was reported (-1.56). After adjusting for postoperative complications, there were statistically significant changes in BREAST-Q subscale scores. Changes observed on the HADS and IES provided external validation of the findings obtained on the BREAST-Q.The current results suggested that the gains in breast satisfaction, psychosocial well being, and sexual well being after patients undergo either free muscle-sparing transverse rectus abdominis myocutaneous flap reconstruction or deep inferior epigastric artery flap reconstruction are statistically significant and clinically meaningful to the patient as early as 3 weeks after surgery. However, these gains are accompanied by significant deterioration in physical well being of the abdominal donor site.Copyright © 2011 American Cancer Society.

The deep inferior epigastric perforator (DIEP) flap, which is a modification of the muscle-sparing free transverse rectus abdominis musculocutaneous (TRAM) flap, is being more frequently used in an effort to reduce postoperative abdominal morbidity. However, there is no consensus as to which of these flaps is superior. The authors aimed to compare quantitative measurements of abdominal function obtained with an isokinetic dynamometer after DIEP and muscle-sparing free TRAM flap elevation.Patients who underwent unilateral single-pedicled DIEP (n = 42) or muscle-sparing free TRAM flap (n = 36) breast reconstruction performed by a single surgeon were included in this study. Preoperative and postoperative trunk flexion parameters were measured prospectively using an isokinetic dynamometer in all patients. The occurrence of postoperative pain, stiffness, and bulging along with patient activity level were also investigated.At 3 months postoperatively, abdominal functions were decreased in both groups, with a larger decline in the muscle-sparing free TRAM flap group. However, at 6 months postoperatively, abdominal muscle function recovered to preoperative levels in both groups. These findings were consistent with the absence of a statistically significant difference in patient postoperative abdominal pain and stiffness, activity level, and the incidence of bulging between the two groups at 6 months postoperatively.From these results, we propose that the surgeon can select the muscle-sparing free TRAM flap, without hesitation or concern regarding abdominal morbidity, when a thick and reliable perforator does not exist and multiple thin perforators must be incorporated.Therapeutic, III.

There are few studies that compare the deep inferior epigastric artery perforator (DIEP) flap to the pedicled transverse rectus abdominis myocutaneous (pTRAM) flap for use in reconstructive breast surgery. The authors examined four factors that aid in decision-making: donor-site morbidity, need for surgery related to abdominal morbidity, operative time, and complications.This is a retrospective review of patients undergoing breast reconstruction using the DIEP or pTRAM flap at the University of British Columbia between 2002 and 2013. The authors compared operative time and abdomen- and flap-related complications in both groups.Reconstruction was performed in 507 patients; 25.6 percent received DIEP flaps (n = 183 breasts) and 74.4 percent underwent pTRAM flap surgery (n = 444 breasts). Pedicled TRAM flap patients were more likely to require abdominal closure with mesh (44.2 percent versus 8.1 percent; p < 0.001); 21.2 percent of them had a postoperative bulge and/or hernia versus 3.1 percent of DIEP flap patients; and 12.7 percent of pTRAM flap patients required surgery for hernia/bulge. Controlling for confounders, there were five times the odds of a hernia/bulge in the pTRAM flap group. DIEP flap surgery was 234 minutes longer than pTRAM flap surgery.The benefits of the pTRAM flap may be offset by the need to correct abdominal wall complications. DIEP flap reconstruction had lower donor complications but increased operative time. A cost analysis is needed to determine the most economical procedure.Therapeutic, III.

The deep inferior epigastric perforator (DIEP) flap has become a popular option for breast reconstruction because of reduced donor-site morbidity. As the number of perforators per flap is reduced, vascular compromise may develop. Venous congestion can occur despite patent primary venous anastomosis.A prospective series of 100 consecutive DIEP flaps in breast reconstruction were studied for vascular problems and outcomes.Ninety-nine flaps were successful. No arterial compromise occurred. Overall, venous congestion occurred in 15 flaps. Eleven flaps developed intraoperative venous congestion, but only five flaps required vascular bypass between the superficial epigastric vein and chest wall vein for additional drainage. One flap was lost because of the authors' failure to recognize and manage inadequate venous outflow by the chosen perforator vein. One flap suffered major fat necrosis because of postoperative thrombosis of the saphenous vein bypass. Overall, fat necrosis occurred in 12 flaps.DIEP venous congestion, despite patent primary venous anastomosis, occurs in 5 percent of these flaps and can be managed successfully by a second venous bypass between the superficial epigastric vein and any chest wall vein. Failure to recognize and manage this can cause flap loss.

The deep inferior epigastric 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. Despite several studies on surgical technique and improvements of flap harvest, only a small number of studies addressing donor site aesthetic exist.A systematic review was performed on donor site aesthetic after DIEP flap harvest according to the PRISMA guidelines. Secondary interests were abdominal wall morbidity and complication rates in general. The following electronic databases were included to identify relevant studies: Medline, Embase, PubMed, Cochrane, and Web of Science.The search yielded 95 articles for full-text analysis, with only four key studies found on donor site aesthetic specifically. Regarding complication rates, the overall rate of abdominal hernia ranges from 0 to 7.1%. Abdominal bulging occurs in 2.3% to 33%. Besides abdominal wall integrity, wound dehiscence (12-39%), seroma (1-48%), hematoma (1-15%), infections (1-12%), fat necrosis (0-11%) and umbilical necrosis (2-3%) significantly impair donor site aesthetic.This systematic review reveals that the topic of donor site aesthetic and potential improvement of results has largely been neglected in the past decade. This study provides a thorough evaluation of potential problems that plastic surgeons may encounter and includes recommendations to improve results.

目的&nbsp;&nbsp;&nbsp; 分析总结保留乳头乳晕的乳房切除术联合腹壁下深动脉穿支皮瓣（DIEP）即刻乳房重建的临床效果和操作经验。 方法&nbsp;&nbsp;&nbsp; 回顾性分析复旦大学附属华山医院甲乳外科2016年1月至2018年10月行全乳切除联合DIEP即刻乳房重建81例临床资料，比较在联合DIEP即刻重建时，保留乳头乳晕（NSM组，38例）和未保留乳头乳晕（非NSM组，43例）的全乳切除两种不同术式的手术成功率、安全性、并发症、病人满意度等。 结果&nbsp;&nbsp;&nbsp; 81例DIEP均存活，无皮瓣丢失。未出现乳房皮肤坏死、术区感染、皮下积液。NSM组分别有1例（2.6%）血管危象和2例（5.3%）部分脂肪坏死，非NSM组分别有2例（4.7%）血管危象和2例（4.7%）部分脂肪坏死，组间差异无统计学意义（P&gt;0.05）。NSM组NAC血运障碍3例（7.9%），未出现完全坏死。术后6个月，NSM组满意率81.6%，高于非NSM组（72.1%），但两组差异无统计学意义（P=0.315）。中位随访时间22（8～42）个月，无局部复发和远处转移。结论&nbsp;&nbsp;&nbsp; 在准确把握手术指征及掌握手术技巧的前提下，NSM联合DIEP即刻乳房重建安全可靠，较不保留乳头乳晕的手术，不增加并发症，NAC坏死率可控，病人满意度高。

Immediate breast reconstruction results in a superior cosmetic outcome. However, immediate breast reconstruction using both prosthetic and autologous techniques is associated with significantly higher complication rates than delayed procedures. These early postoperative complications are usually related to unrecognized ischemia of mastectomy skin and/or inadequate perfusion of autologous tissue used for reconstruction. Aside from clinical experience, there are no reliable tools to assist the novice surgeon with intraoperative assessment of tissue viability.Laser-assisted indocyanine green imaging was applied to determine and map tissue perfusion. Indocyanine green perfusion mapping was used in 24 consecutive breast reconstructions to define the perfusion of both mastectomy skin and autologous tissue. Areas of inadequate perfusion were then removed at the time of surgery. Postoperative complications occurring within 90 days after surgery were reviewed.In 24 consecutive breast reconstruction (16 tissue expanders, two latissimus dorsi flaps, and six deep inferior epigastric perforator/superficial inferior epigastric arteries), there was a 4 percent complication rate. Intraoperatively, the use of indocyanine green imaging allowed all poorly perfused skin to be removed completely in each case, minimizing the incidence of mastectomy flap necrosis, partial necrosis of autologous tissue, and impaired healing. For autologous reconstruction, patency of anastomoses could also be confirmed. This complication rate was significantly less than the 15.1 percent complication rate observed in 206 reconstructions in the previous consecutive 148 patients (p < 0.01) with similar demographics and risk factors.This early experience demonstrates an increased accuracy in predicting tissue necrosis (mastectomy flap, autologous tissue) as guided by indocyanine green imaging. Further prospective studies are warranted to quantify whether this technology can reduce health care costs by preventing complications in immediate breast reconstruction.

Improved self-image and psychological well-being after breast reconstruction are well documented. To determine methods that optimized results with minimal morbidity, the authors examined their results and complications based on reconstruction method and timing.The authors reviewed all breast reconstructions after mastectomy for breast cancer performed under the supervision of a single surgeon over a 6-year period at a tertiary referral center. Reconstruction method and timing, patient characteristics, and complication rates were reviewed.Reconstruction was performed on 240 consecutive women (94 bilateral and 146 unilateral; 334 total reconstructions). Reconstruction timing was evenly split between immediate (n = 167) and delayed (n = 167). Autologous tissue (n = 192) was more common than tissue expander/implant reconstruction (n = 142), and the free deep inferior epigastric perforator was the most common free flap (n = 124). The authors found no difference in the complication incidence with autologous reconstruction, whether performed immediately or delayed. However, there was a significantly higher complication rate following immediate placement of a tissue expander when compared with delayed reconstruction (p = 0.008). Capsular contracture was a significantly more common late complication following immediate (40.4 percent) versus delayed (17.0 percent) reconstruction (p < 0.001; odds ratio, 5.2; 95 percent confidence interval, 2.3 to 11.6).Autologous reconstruction can be performed immediately or delayed, with optimal aesthetic outcome and low flap loss risk. However, the overall complication and capsular contracture incidence following immediate tissue expander/implant reconstruction was much higher than when performed delayed. Thus, tissue expander placement at the time of mastectomy may not necessarily save the patient an extra operation and may compromise the final aesthetic outcome.

The purpose of the study was to evaluate the detection of vascular complications earlier than clinical evidence using a noninvasive near-infrared tissue oximeter monitor. Early detection of circulatory compromise allows for earlier re-exploration and better outcomes. The monitoring method studied was the ViOptix T.Ox Tissue Oximeter (ViOptix Inc., Fremont, CA). The device uses an optical tissue characterization based on measuring scattering and absorption of near infrared light. Tissue oxygen saturation and its derivates were evaluated as candidates for a more sensitive algorithm to predict vascular flap complications. Criteria studied in various combinations were the absolute value of tissue oxygen saturation (StO2), the amount of its change (DeltaStO2) and the rate of its change (DeltaStO2/Deltat). There were 208 monitored breast flaps in 145 patients (62 bilateral and 83 unilateral). In 1 patient, 2 flaps were used to make a single breast. Patients were monitored intraoperatively and postoperatively for 36 hours. No flap being monitored was lost. Among the 208 flaps monitored, 5 patients exhibited complications that were predicted by the tissue oximeter before clinical signs were evident. If blood flow was completely occluded by either venous or arterial thrombosis, the tissue oximeter provided information that enabled diagnosis to be made in about 1 hour. The drop rate indicator DeltaStO2/Deltat, when it is equal to or greater than 20% per hour sustained more than 30 minutes predicted vascular complications. The use of the new diagnostic algorithm with the T.Ox Tissue Oximeter monitor was successful in predicting flap complication within 1 hour of the onset of the occlusive event with a high diagnostic accuracy in the 208 flap procedures.

In the deep inferior epigastric perforator (DIEP) flap breast reconstruction, fat necrosis is a common and distressing complication for patients. While venous outflow augmentation using the superficial inferior epigastric vein (SIEV) has been suggested to improve some perfusion-related outcomes, its effect on fat necrosis remains insufficiently substantiated.A retrospective review was conducted of unilateral, unipedicled DIEP flap breast reconstructions performed between 2012 and 2023 at a tertiary centre in London, United Kingdom. Patients were categorised based on SIEV venous augmentation status, and the incidence of postoperative clinical fat necrosis was recorded. Univariable and multivariable logistic regression models assessed the relationship between fat necrosis and SIEV augmentation, as well as patient, surgical and perfusion-related factors.The total cohort included 119 patients (119 flaps). Of the total flaps, 58.8% received venous augmentation with the SIEV. Fat necrosis occurred in 16.8% of the total cases. Patients in the SIEV-augmented group experienced significantly lower fat necrosis rates compared to controls (10.0% vs. 26.5%, respectively; P = 0.025). Multivariable analysis further demonstrated a protective effect from SIEV augmentation against fat necrosis (adjusted odds ratio 0.33, 95% confidence interval 0.12-0.95; P = 0.039).In the present cohort of DIEP flap breast reconstructions, venous augmentation using SIEV was a significant independent protective factor against fat necrosis. While prospective studies are necessary to validate this relationship, this technique may be considered as part of routine surgical practice in eligible cases.Copyright © 2025 The Author(s). Published by Elsevier Ltd.. All rights reserved.

Preoperative CT-angiography (CTA) has shown to reduce operative time in deep inferior epigastric perforator (DIEP) flap breast reconstruction compared to Doppler ultrasonography (US). Although decreased flap loss has been suggested, statistical significant reduction remains indeterminate. The purpose of this review is to evaluate flap loss after preoperative CTA and Doppler US in DIEP-flap breast reconstruction.A systematic literature search was performed in MEDLINE, EMBASE, and Cochrane libraries. All articles comparing CTA to Doppler US were selected and critically appraised; data on flap loss were extracted.From 678 studies, eight were selected for appraisal. Six case-control studies were included in the final analysis. Pooled analysis showed CTA resulted in a significant reduction in partial necrosis (odds ratio/OR 0.15; 95% confidence interval/CI 0.07-0.32, P < 0.0001) and decreased flap loss (OR 0.28; 95% CI 0.10-0.79, P = 0.02).Studies included in this meta-analysis have several limitations. However, most studies find a large clinical advantage of CTA over Doppler US, which reaches statistical significance when combined. As results show that CTA prior to DIEP flap breast reconstruction offers significant clinical benefits, we suggest the routine use of preoperative CTA.Copyright © 2013 Wiley Periodicals, Inc.

The use of perforator flaps in breast reconstructions has increased considerably in the past decade. A disadvantage of the perforator flap is difficult dissection, which results in a longer procedure. During spring 2006, we introduced CT angiography (CTA) as part of the diagnostic work-up in perforator flap reconstructions to visualise each perforator more accurately. The main objectives were to reduce surgery time and the number of complications. A chart review was conducted 1 year after CTA introduction to investigate if these objectives were met.Patients with a deep inferior epigastric perforator (DIEP) flap who underwent preoperative analysis through CTA were retrospectively evaluated. The population <or=1 year before CTA introduction were the control group. The two groups were compared with respect to surgery time and complications (including flap failure).One hundred and thirty-eight DIEP breast reconstructions were done; 70 underwent preoperative CTA analysis, and 68 had preoperative Doppler investigation. Surgery time in the CTA group was significantly lower (P<0.001) than in the control group, 264 min (SD+/-62) versus 354 min (SD+/-83), respectively. There was a tendency for fewer complications in the CTA group compared with the control group. All flaps were successful in the CTA group. In the control group, one flap failed and partial necrosis occurred in three flaps. The differences were not statistically significant.Preoperative CTA in the assessment of vascular anatomy during perforator flap reconstruction was safe and reliable. It helped reduce surgery time, and may prevent the number of postoperative complications.

The purpose of this study was to critically evaluate the perioperative complications for deep inferior epigastric perforator (DIEP) flap breast reconstruction.From February 2002 until February 2006, 175 consecutive abdominal free tissue breast reconstructions were performed in 131 patients. Perioperative risk factors and complications were evaluated for the entire group. Data analysis was performed to compare subsequent chronologic groups for a learning curve effect.In 159 cases (90.9%) a DIEP flap could be raised. In 13 cases (7.4%), a mini-TRAM flap and in 3 cases (1.7%) a regular free TRAM flap was harvested. A learning curve was found showing a risk for flap complications in the first 30 DIEP flaps of 40% and in flaps 31 to 175 of 13.8% (P < 0.012). Microsurgical revision rate was 4% (n = 7), with a total flap failure rate of 0.6% (n = 1). Partial flap failure rate was 8.6% (n = 15), which was solved by debridement, medial advancement, and direct closure in 6.8% (n = 12) and latissimus dorsi flap transposition in 1.8% (n = 3). Multivariate analysis showed no significant influence of risk factors on development of postoperative flap complications.DIEP flap breast reconstruction is an excellent method, with limited donor-site morbidity. A definite learning curve was reflected in a larger number of flap complications in the beginning of our series.