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CC BY-NC-ND 4.0 · J Reconstr Microsurg Open 2021; 06(01): e20-e27
DOI: 10.1055/s-0041-1729638
Original Article

Necrosis or Flap Loss After Deep Inferior Epigastric Perforator Reconstruction: Impact of Perforators and Recipient Vessels

Johanna S. Palve
1   Department of Plastic Surgery, Tampere University, Faculty of Medicine and Health Technology and Tampere University Hospital, Tampere, Finland
,
Tiina H. Luukkaala
2   Research, Development and Innovation Center, Tampere University Hospital and Health Sciences, Faculty of Social Sciences, Tampere University, Tampere, Finland
,
Minna T. Kääriäinen
1   Department of Plastic Surgery, Tampere University, Faculty of Medicine and Health Technology and Tampere University Hospital, Tampere, Finland
› Author Affiliations Funding This study received its financial support from Tampere University Hospital support foundation.
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Abstract

Background The aim of this study is to analyze the impact of the number and location of perforators harvested and the recipient vessels used on deep inferior epigastric perforator (DIEP) flap survival and the occurrence of flap necrosis requiring re-operation.

Patients and Methods Four hundred and seventy-one DIEP flap reconstructions, performed between January 2008 and December 2019, were retrospectively analyzed.

Results Flap necrosis requiring re-operation was observed in 40 (9%) of flaps and total flap loss rate was 1% (n = 6). No significant differences were observed between internal mammary vessels (IMV, n = 287, 61%) and thoracodorsal vessels (TDV, n = 184, 39%) regarding postoperative re-anastomosis (p = 0.529) or flap survival (p = 0.646). Intraoperative conversion from IMV to TDV was performed on 64 (14%) patients. TDV were more commonly associated with problems in preparation of the vessels than IMV (p < 0.001). Second vein anastomosis was performed on 18 (4%) patients. In total, 81 flaps (17%) had one perforator, 165 (35%) had two, 218 (46%) had three to five, and 7 (2%) had more than five perforators. Flaps with three to five perforators were more commonly associated with flap necrosis (p < 0.001) than flaps with one or two perforators. Independent factors associated with necrosis were body mass index (BMI) > 30 (odds ratio [OR]: 2.28; 95% confidence interval: 1.06–4.91, p = 0.035) and perforator/s located on the lateral row (OR: 3.08, 95% CI 1.29–7.33, p = 0.011).

Conclusion We conclude that the occurrence of flap necrosis requiring re-operation may be higher in DIEP flaps with more than two perforators or perforator/s located on the lateral row and in obese patients. Neither the recipient vessels used nor the number of perforators harvested had any impact on the flap survival rate.

Keywords

deep inferior epigastric perforator - perforator - recipient vessel - flap necrosis


Publication History

Received: 20 October 2020

Accepted: 11 January 2021

Article published online:
15 June 2021

© 2021. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/)

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  • References

  • 1 Lee KT, Mun GH. Perfusion of the DIEP flaps: a systematic review with meta-analysis. Microsurgery 2018; 38 (01) 98-108
    CrossrefPubMedGoogle Scholar
  • 2 Mijuskovic B, Tremp M, Heimer MM. et al. Color Doppler ultrasound and computed tomographic angiography for perforator mapping in DIEP flap breast reconstruction revisited: a cohort study. J Plast Reconstr Aesthet Surg 2019; 72 (10) 1632-1639
    CrossrefPubMedGoogle Scholar
  • 3 Bhullar H, Hunter-Smith DJ, Rozen WM. Fat necrosis after DIEP flap breast reconstruction: a review of perfusion-related causes. Aesthetic Plast Surg 2020; 44 (05) 1454-1461
    CrossrefPubMedGoogle Scholar
  • 4 Hummelink S, Hoogeveen YL, Schultze Kool LJ, Ulrich DJO. A new and innovative method of preoperatively planning and projecting vascular anatomy in DIEP flap breast reconstruction: a randomized controlled trial. Plast Reconstr Surg 2019; 143 (06) 1151e-1158e
    CrossrefPubMedGoogle Scholar
  • 5 Hembd A, Teotia SS, Zhu H, Haddock NT. Optimizing perforator selection: a multivariable analysis of predictors for fat necrosis and abdominal morbidity in DIEP flap breast reconstruction. Plast Reconstr Surg 2018; 142 (03) 583-592
    CrossrefPubMedGoogle Scholar
  • 6 Rose JF, Zavlin D, Garrett AE, Chegireddy V, Ellsworth IV WA. Evaluation of the single medial circummuscular perforator DIEP flap: outcomes and comparison to traditional transmuscular single perforator flap. Microsurgery 2018; 38 (05) 479-488
    CrossrefPubMedGoogle Scholar
  • 7 Scheflan M, Dinner MI. The transverse abdominal island flap: part I. Indications, contraindications, results, and complications. Ann Plast Surg 1983; 10 (01) 24-35
    CrossrefPubMedGoogle Scholar
  • 8 Scheflan M, Dinner MI. The transverse abdominal island flap: part II. Surgical technique. Ann Plast Surg 1983; 10 (02) 120-129
    CrossrefPubMedGoogle Scholar
  • 9 Hartrampf CR, Scheflan M, Black PW. Breast reconstruction with a transverse abdominal island flap. Plast Reconstr Surg 1982; 69 (02) 216-225
    CrossrefPubMedGoogle Scholar
  • 10 Holm C, Mayr M, Höfter E, Ninkovic M. Perfusion zones of the DIEP flap revisited: a clinical study. Plast Reconstr Surg 2006; 117 (01) 37-43
    CrossrefPubMedGoogle Scholar
  • 11 Saint-Cyr M, Wong C, Schaverien M, Mojallal A, Rohrich RJ. The perforasome theory: vascular anatomy and clinical implications. Plast Reconstr Surg 2009; 124 (05) 1529-1544
    CrossrefPubMedGoogle Scholar
  • 12 Wade RG, Watford J, Wormald JCR, Bramhall RJ, Figus A. Perforator mapping reduces the operative time of DIEP flap breast reconstruction: a systematic review and meta-analysis of preoperative ultrasound, computed tomography and magnetic resonance angiography. J Plast Reconstr Aesthet Surg 2018; 71 (04) 468-477
    CrossrefPubMedGoogle Scholar
  • 13 Rozen WM, Bhullar HK, Hunter-Smith D. How to assess a CTA of the abdomen to plan an autologous breast reconstruction. Gland Surg 2019; 8 (Suppl. 04) S291-S296
    CrossrefPubMedGoogle Scholar
  • 14 Grover R, Nelson JA, Fischer JP, Kovach SJ, Serletti JM, Wu LC. The impact of perforator number on deep inferior epigastric perforator flap breast reconstruction. Arch Plast Surg 2014; 41 (01) 63-70
    Article in Thieme ConnectPubMedGoogle Scholar
  • 15 Baumann DP, Lin HY, Chevray PM. Perforator number predicts fat necrosis in a prospective analysis of breast reconstruction with free TRAM, DIEP, and SIEA flaps. Plast Reconstr Surg 2010; 125 (05) 1335-1341
    CrossrefPubMedGoogle Scholar
  • 16 Gill PS, Hunt JP, Guerra AB. et al. A 10-year retrospective review of 758 DIEP flaps for breast reconstruction. Plast Reconstr Surg 2004; 113 (04) 1153-1160
    CrossrefPubMedGoogle Scholar
  • 17 Santanelli Di Pompeo F, Longo B, Sorotos M, Pagnoni M, Laporta R. The axillary versus internal mammary recipient vessel sites for breast reconstruction with diep flaps: a retrospective study of 256 consecutive cases. Microsurgery 2015; 35 (01) 34-38
    CrossrefPubMedGoogle Scholar
  • 18 Banwell M, Trotter D, Ramakrishnan V. The thoracodorsal artery and vein as recipient vessels for microsurgical breast reconstruction. Ann Plast Surg 2012; 68 (05) 542-543
    CrossrefPubMedGoogle Scholar
  • 19 Leppard W, Pomposelli T, Chang EI, Suliman A, Herrera F. Internal mammary usability as recipient vessels in DIEP breast reconstruction in the setting of previous radiation. J Plast Reconstr Aesthet Surg 2018; 71 (08) 1123-1128
    CrossrefPubMedGoogle Scholar
  • 20 Temple CL, Strom EA, Youssef A, Langstein HN. Choice of recipient vessels in delayed TRAM flap breast reconstruction after radiotherapy. Plast Reconstr Surg 2005; 115 (01) 105-113
    CrossrefPubMedGoogle Scholar
  • 21 Opsomer D, D'Arpa S, Benmeridja L, Stillaert F, Noel W, Van Landuyt K. Bilateral DIEP flap breast reconstruction to a single set of internal mammary vessels: technique, safety, and outcomes after 250 flaps. Plast Reconstr Surg 2019; 144 (04) 554e-564e
    CrossrefPubMedGoogle Scholar
  • 22 La Padula S, Hersant B, Noel W. et al. Use of the retrograde limb of the internal mammary vein to avoid venous congestion in DIEP flap breast reconstruction: further evidences of a reliable and time-sparing procedure. Microsurgery 2016; 36 (06) 447-452
    CrossrefPubMedGoogle Scholar
  • 23 Blondeel PN, Arnstein M, Verstraete K. et al. Venous congestion and blood flow in free transverse rectus abdominis myocutaneous and deep inferior epigastric perforator flaps. Plast Reconstr Surg 2000; 106 (06) 1295-1299
    CrossrefPubMedGoogle Scholar
  • 24 Karadsheh MJ, Shafqat MS, Krupp JC, Weiss ES, Patel SA. A theoretical model describing the dynamics of venous flow in the DIEP flap. J Reconstr Microsurg 2019; 35 (09) 688-694
    Article in Thieme ConnectPubMedGoogle Scholar
  • 25 Sbitany H, Lentz R, Piper M. The “dual-plane” DIEP flap: measuring the effects of superficial arterial and venous flow augmentation on clinical outcomes. J Reconstr Microsurg 2019; 35 (06) 411-416
    Article in Thieme ConnectPubMedGoogle Scholar
  • 26 Kerr-Valentic MA, Gottlieb LJ, Agarwal JP. The retrograde limb of the internal mammary vein: an additional outflow option in DIEP flap breast reconstruction. Plast Reconstr Surg 2009; 124 (03) 717-721
    CrossrefPubMedGoogle Scholar
  • 27 Bozikov K, Arnez T, Hertl K, Arnez ZM. Fat necrosis in free DIEAP flaps: incidence, risk, and predictor factors. Ann Plast Surg 2009; 63 (02) 138-142
    CrossrefPubMedGoogle Scholar
  • 28 Prantl L, Moellhoff N, Fritschen UV. et al. Impact of smoking status in free deep inferior epigastric artery perforator flap breast reconstruction: a multicenter study. J Reconstr Microsurg 2020; 36 (09) 694-702
    Article in Thieme ConnectPubMedGoogle Scholar
  • 29 Daly LT, Doval AF, Lin SJ, Tobias A, Lee BT, Dowlatshahi AS. Role of CTA in women with abdominal scars undergoing DIEP breast reconstruction: review of 1,187 flaps. J Reconstr Microsurg 2020; 36 (04) 294-300
    Article in Thieme ConnectPubMedGoogle Scholar
  • 30 Kamali P, Lee M, Becherer BE. et al. Medial row perforators are associated with higher rates of fat necrosis in bilateral DIEP flap breast reconstruction. Plast Reconstr Surg 2017; 140 (01) 19-24
    CrossrefPubMedGoogle Scholar