Optimizing Outcomes in Free Flap Breast Reconstruction in the Community Hospital Setting: A Stepwise Approach to DIEP/SIEA Flap Procedures with Banking a Hemiabdominal Flap

Alberto Okada; Diego Daniel Pereira; Eduardo Montag; Marcelo Portocarrero; Carlos Felício; Eduardo Gustavo Arruda; Alexandre Fonseca; Rolf Gemperli; Alexandre Mendonça Munhoz

doi:10.1055/s-0037-1602588

Journal of Reconstructive Microsurgery, Inhaltsverzeichnis

J Reconstr Microsurg 2017; 33(07): 474-482
DOI: 10.1055/s-0037-1602588

Original Article

Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Optimizing Outcomes in Free Flap Breast Reconstruction in the Community Hospital Setting: A Stepwise Approach to DIEP/SIEA Flap Procedures with Banking a Hemiabdominal Flap

Alberto Okada

¹Division of Plastic Surgery, Cancer Institute of São Paulo, University of São Paulo School of Medicine, São Paulo, Brazil

,

Diego Daniel Pereira

¹Division of Plastic Surgery, Cancer Institute of São Paulo, University of São Paulo School of Medicine, São Paulo, Brazil

,

Eduardo Montag

¹Division of Plastic Surgery, Cancer Institute of São Paulo, University of São Paulo School of Medicine, São Paulo, Brazil

,

Marcelo Portocarrero

¹Division of Plastic Surgery, Cancer Institute of São Paulo, University of São Paulo School of Medicine, São Paulo, Brazil

,

Carlos Felício

¹Division of Plastic Surgery, Cancer Institute of São Paulo, University of São Paulo School of Medicine, São Paulo, Brazil

,

Eduardo Gustavo Arruda

¹Division of Plastic Surgery, Cancer Institute of São Paulo, University of São Paulo School of Medicine, São Paulo, Brazil

,

Alexandre Fonseca

¹Division of Plastic Surgery, Cancer Institute of São Paulo, University of São Paulo School of Medicine, São Paulo, Brazil

,

Rolf Gemperli

²Division of Plastic Surgery, University of São Paulo School of Medicine, São Paulo, Brazil

,

Alexandre Mendonça Munhoz

³Division of Plastic Surgery, Hospital Sírio-Libanês, São Paulo, Brazil

⁴Division of Breast Reconstruction, Cancer Institute of São Paulo, Hospital Sírio-Libanês, University of São Paulo School of Medicine, São Paulo, Brazil

› Institutsangaben

Abstract

Background Free flap breast reconstruction is a conventional procedure in many countries; however, microvascular compromise remains a devastating outcome. Given the morbidity of total necrosis, optimizing free flap salvage stands out as an important area for research, especially among surgeons to overcome the learning curve period and in resource constrained scenario such as community hospitals. To ensure free deep inferior epigastric perforator (DIEP)/superficial inferior epigastric artery (SIEA) flap breast reconstruction, the authors present a technique involving raising a hemiabdominal flap as a free flap, and banking the remaining flap to be utilized if needed in a subsequent procedure.

Methods A retrospective review was performed on all free flap breast reconstructions. In this period, 84 patients (mean age: 50.1 ± 8 years) were included.

Results In this study, 65.5% patients underwent immediate reconstruction, and 51.2% received DIEP reconstruction; 9.52% patients were returned to the operating room, and salvage reconstruction using the banked flap was performed in all patients. No differences were observed regarding early complications and age, body mass index, American Society of Anesthesiologists status, diabetes, smoking history, chemotherapy, radiotherapy, and type of flap used (p > 0.05). Hypertension was significantly associated with early complications (p < 0.05). Donor-site complications were associated with RT (p < 0.05).

Conclusion The banked flap is a reliable method for ensuring DIEP/SIEA flap survival and should be considered in higher risk reconstructions and community hospitals. We believe that the present technique can be a good addition to the arsenal of plastic surgeons dealing with free flap breast reconstructions in selected patients.

Keywords

breast reconstruction - microsurgery - outcome

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Referenzen

References
1 Malyon AD, Husein M, Weiler-Mithoff EM. How many procedures to make a breast?. Br J Plast Surg 2001; 54 (03) 227-231
2 Losken A, Carlson GW, Schoemann MB, Jones GE, Culbertson JH, Hester TR. Factors that influence the completion of breast reconstruction. Ann Plast Surg 2004; 52 (03) 258-261 , discussion 262
3 Alderman AK, Wilkins EG, Kim HM, Lowery JC. Complications in postmastectomy breast reconstruction: two-year results of the Michigan Breast Reconstruction Outcome Study. Plast Reconstr Surg 2002; 109 (07) 2265-2274
4 Sullivan SR, Fletcher DR, Isom CD, Isik FF. True incidence of all complications following immediate and delayed breast reconstruction. Plast Reconstr Surg 2008; 122 (01) 19-28
5 Petersen A, Eftekhari AL, Damsgaard TE. Immediate breast reconstruction: a retrospective study with emphasis on complications and risk factors. J Plast Surg Hand Surg 2012; 46 (05) 344-348
6 Saint-Cyr M, Chang DW, Robb GL, Chevray PM. Internal mammary perforator recipient vessels for breast reconstruction using free TRAM, DIEP, and SIEA flaps. Plast Reconstr Surg 2007; 120 (07) 1769-1773
7 Knight MA, Nguyen IV DT, Kobayashi MR, Evans GR. Institutional review of free TRAM flap breast reconstruction. Ann Plast Surg 2006; 56 (06) 593-598
8 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
9 Wormald JC, Wade RG, Figus A. The increased risk of adverse outcomes in bilateral deep inferior epigastric artery perforator flap breast reconstruction compared to unilateral reconstruction: a systematic review and meta-analysis. J Plast Reconstr Aesthet Surg 2014; 67 (02) 143-156
10 Lineaweaver W, Akdemir O, Schleich A. Management strategies following microsurgical flap failure. Microsurgery 2010; 30 (01) 61-63
11 Kovach SJ, Georgiade GS. The “banked” TRAM: a method to insure mastectomy skin-flap survival. Ann Plast Surg 2006; 57 (04) 366-369
12 Shridharani SM, Singh NK, Taylor JA, Rosson GD. Banking a hemi-abdominal DIEP flap: a pilot report of indications, technique, and utility. Microsurgery 2009; 29 (04) 265-269
13 Gupta S. The impact of evolving V.A.C ® Therapy technology on outcomes in wound care. Prologue. Int Wound J 2012; 9 (Suppl. 01) iii-vii
14 Hamdi M, Andrades P, Thiessen F. , et al. Is a second free flap still an option in a failed free flap breast reconstruction?. Plast Reconstr Surg 2010; 126 (02) 375-384
15 Mathes SJ, Alkureishi LW. Secondary breast reconstruction. In: Mathes SJ. , ed. Plastic Surgery. Philadelphia: Saunders Elsevier; 2006: 1083-1174
16 Munhoz AM, Montag E, Arruda EG. , et al. The use of contralateral free extended latissimus dorsi myocutaneous flap for a tertiary failed breast reconstruction: is it still an option?. J Plast Reconstr Aesthet Surg 2016; 69 (08) 1087-1091
17 Bodin F, Dissaux C, Lutz JC, Hendriks S, Fiquet C, Bruant-Rodier C. The DIEP flap breast reconstruction: starting from scratch in a university hospital. Ann Chir Plast Esthet 2015; 60 (03) 171-178
18 Hofer SO, Damen TH, Mureau MA, Rakhorst HA, Roche NA. A critical review of perioperative complications in 175 free deep inferior epigastric perforator flap breast reconstructions. Ann Plast Surg 2007; 59 (02) 137-142
19 Sando IC, Momoh AO, Chung KC, Kozlow JH. The early years of practice: n assessment of operative efficiency and cost of free flap and implant breast reconstruction at an academic institution. J Reconstr Microsurg 2016; 32 (06) 445-454
20 Munhoz AM, Arruda E, Montag E. , et al. Immediate skin-sparing mastectomy reconstruction with deep inferior epigastric perforator (DIEP) flap. Technical aspects and outcome. Breast J 2007; 13 (05) 470-478
21 Munhoz AM, Montag E, Filassi JR, Gemperli R. Immediate nipple-areola-sparing mastectomy reconstruction: an update on oncological and reconstruction techniques. World J Clin Oncol 2014; 5 (03) 478-494
22 Massenburg BB, Sanati-Mehrizy P, Taub PJ. Age as a risk factor for flap failure in free tissue transfer. J Craniofac Surg 2015; 26 (07) e679
23 Saçak B, Akdeniz ZD, Certel F, Kocaaslan FN, Tuncer B, Çelebiler Ö. Risk assessment for free tissue transfers: is old age a determining factor?. J Craniofac Surg 2015; 26 (03) 856-859
24 Lakatta EG. Age-associated cardiovascular changes in health: impact on cardiovascular disease in older persons. Heart Fail Rev 2002; 7 (01) 29-49
25 Duraes EF, Schwarz G, Durand P. , et al. Complications following abdominal-based free flap breast reconstruction: is a 30 days complication rate representative?. Aesthetic Plast Surg 2015; 39 (05) 694-699
26 Massenburg BB, Sanati-Mehrizy P, Ingargiola MJ, Rosa JH, Taub PJ. Flap Failure and wound complications in autologous breast reconstruction: a national perspective. Aesthetic Plast Surg 2015; 39 (06) 902-909
27 Laurent S, Boutouyrie P. The structural factor of hypertension: large and small artery alterations. Circ Res 2015; 116 (06) 1007-1021
28 Munhoz AM, Ishida LH, Montag E. , et al. Internal mammary perforator vessels as recipient site for microsurgical breast reconstruction: a comparative histomorphometric analysis and incidence of degenerative vascular changes. Microsurgery 2014; 34 (03) 217-223
29 Sanati-Mehrizy P, Massenburg BB, Rosa JH, Taub PJ. Risk factors associated with free flap failure - an analysis of 2103 patients. Plast Reconstr Surg 2015; 136 (4, Suppl): 18-19
30 Chang EI, Liu TS, Festekjian JH, Da Lio AL, Crisera CA. Effects of radiation therapy for breast cancer based on type of free flap reconstruction. Plast Reconstr Surg 2013; 131 (01) 1e-8e
31 Fosnot J, Fischer JP, Smartt Jr JM. , et al. Does previous chest wall irradiation increase vascular complications in free autologous breast reconstruction?. Plast Reconstr Surg 2011; 127 (02) 496-504
32 Coroneos CJ, Heller AM, Voineskos SH, Avram R. SIEA versus DIEP arterial complications: a cohort study. Plast Reconstr Surg 2015; 135 (05) 802e-807e
33 Selber JC, Samra F, Bristol M. , et al. A head-to-head comparison between the muscle-sparing free TRAM and the SIEA flaps: is the rate of flap loss worth the gain in abdominal wall function?. Plast Reconstr Surg 2008; 122 (02) 348-355
34 Sarik JR, Bank J, Wu LC, Serletti JM. Superficial inferior epigastric artery: learning curve versus reality. Plast Reconstr Surg 2016; 137 (01) 1e-6e
35 Wang XL, Liu LB, Song FM, Wang QY. Meta-analysis of the safety and factors contributing to complications of MS-TRAM, DIEP, and SIEA flaps for breast reconstruction. Aesthetic Plast Surg 2014; 38 (04) 681-691
36 Munhoz AM, Pellarin L, Montag E. , et al. Superficial inferior epigastric artery (SIEA) free flap using perforator vessels as a recipient site: clinical implications in autologous breast reconstruction. Am J Surg 2011; 202 (05) 612-617
37 Salgado CJ, Moran SL, Mardini S. Flap monitoring and patient management. Plast Reconstr Surg 2009; 124 (6, Suppl): e295-e302
38 Munhoz AM, Ishida LH, Sturtz GP. , et al. Importance of lateral row perforator vessels in deep inferior epigastric perforator flap harvesting. Plast Reconstr Surg 2004; 113 (02) 517-524