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DOI: 10.1055/s-0034-1398662
Der DIEP Lappen als Standard in der autologen Brustrekonstruktion – Ergebnisse und Algorithmus zur erfolgreichen Rekonstruktion
The DIEP Flap as Method of Choice in Breast Reconstruction – Results and Protocol for Succesful ReconstructionPublication History
eingereicht 31 October 2014
akzeptiert 13 January 2015
Publication Date:
19 August 2015 (online)
![](https://www.thieme-connect.de/media/hamipla/201504/lookinside/thumbnails/2014-10-0742-80_10-1055-s-0034-1398662-1.jpg)
Zusammenfassung
Hintergrund: Die autologe Brustrekonstruktion gewinnt zunehmend an Bedeutung insbesondere vor dem Hintergrund der erhöhten Raten an prophylaktischen Mastektomien bei BRCA 1–3 Mutationen. Bezüglich der Indikation und Komplikationsrate zwischen freien DIEP und TRAM Lappenplastiken zur autologen Brustrekonstruktion existieren heterogene Daten.
Material und Methoden: Zwischen Januar 2010 und Dezember 2011 erhielten 362 Patientinnen eine autologe Brustrekonstruktion mittels freier DIEP oder MS-2-TRAM Lappenplastik. Die Wahl der Lappenplastik zwischen DIEP und MS-2-TRAM erfolgte standardisiert durch einen Algorithmus mit präoperativer CT-Angiografie, intraoperativer Lappenperfusionskontrolle und Dopplerdetektion. Die Auswertung berücksichtigte Lappenrandnekrosen <20%, Lappenrandnekrosen >20% und komplette Lappenverluste, Fettnekrosen sowie operative Anastomosenrevisionen.
Ergebnisse: Es wurden bei 362 Patienten 419 freie Lappenplastiken zur Brustrekonstruktion durchgeführt (366 DIEP und 53 MS-2-TRAM). Bei 66 Patientinnen erfolgte eine bilaterale Rekonstruktion (52 Doppel DIEPs, 9 DIEP und MS-2-TRAMS sowie 5 Doppel MS-2-TRAMS). Die totale Lappenverlustrate betrug insgesamt 0,24%. Lappenrandnekrosen <20% zeigten sich bei 0,72 % (DIEP 0,82%, MS-2-TRAM 0%), Lappenrandnekrosen >20% bei 0,72% (DIEP 0,69% MS 2 TRAM 0,98%). Bei einer DIEP Lappenplastik kam es zu einem Totalverlust. Die Rate der Anastomosenrevisionen zeigte sich mit insgesamt 0,48% gering. Es zeigte sich keine signifikant erhöhte Komplikationsrate in einer der Gruppen. Nach Einführung des Algorithmus reduzierte sich der Anteil der MS-2-Tram Lappenplastiken im Vergleich zu dem Zeitraum davor um ca. 20% auf Werte zwischen 10,9–13,5% aller Brustrekonstruktionen.
Schlussfolgerung: Durch die Anwendung des vorgestellten Algorithmus ist die Brustrekonstruktion mit freier DIEP Lappenplastik eine sichere Therapieoption wenn sie hochfrequent in einem mikrochirurgischen Zentrum erfolgt. Die Lappenverlust- und Komplikationsrate ist im Vergleich zu MS-2-Tram nicht erhöht. Die Entscheidung zur Selektion der geeigneten Lappenplastik sollte anhand des vorgestellten Algorithmus erfolgen um ein sicheres reproduzierbares Ergebnis zu erzielen.
Abstract
Background: Autologous breast reconstruction is becoming increasingly important, especially in light of the increased rates of prophylactic mastectomies with BRCA mutations. Regarding the indications and complications between free TRAM and free DIEP flaps for autologous breast reconstruction the current data is not clear.
Materials and Methods: All patients who received an autologous breast reconstruction between January 2010 and January 2014 using free DIEP or free MS-2-TRAM flaps were included in the study. The choice of flap between DIEP and MS-2-TRAM was performed by a standardised algorithm with preoperative CT angiography, intraoperative evaluation of the flap perfusion and Doppler detection. The analysis took into account partial flap necrosis <20% and >20%), complete flap loss, flap necrosis and surgical revision of the anastomosis.
Results: The study considered 362 women who received a total of 419 free flaps for breast reconstruction. 66 patients received a bilateral reconstruction (52 double DIEPS, 9 DIEP and MS2 TRAM and 5 double MS2 TRAMs). The total flap loss was 0.24%. Partial necrosis <20% occurred in 0.72% (DIEP 0.82%, MS2 TRAM 0%), partial necrosis >20% in 0.72% (DIEP 0.69% MS2 TRAM 0.98%). One DIEP flap was lost (0.24%). After implementing our protocol the rate of MS-2-Tram flaps could be reduced to 10–15% of all autologous breast reconstruction procedures as compared to the years before.
Conclusion: Through the application of the presented algorithm for breast reconstruction with free DIEP flap, such surgery is a safe treatment option if it is done at high frequency in a microsurgical centre. Flap loss and complications are not increased compared to MS2 TRAM flaps. The decision for the selection of the appropriate flap for breast reconstruction should be based on the presented algorithm in order to achieve secure and reproducible results.
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