he deep inferior epigastric perforator (DIEP) flap is considered the standard in autologous breast reconstruction because it is associated with less postoperative pain and donor-site morbidity compared with muscle-sacrificing techniques, such as the transverse rectus abdominis musculocutaneous (TRAM) flap. 1 However, because DIEP flap surgery involves two donor-site incisions, one around the umbilicus and the other in the lower abdomen, wound complications can occur in the postoperative period.Background: Despite the umbilicus being an essential aesthetic unit, current literature on umbilical outcomes following abdominally based breast reconstruction is limited. In this study, the authors aim to elucidate the incidence and predictors of umbilical complications following deep inferior epigastric perforator (DIEP) flaps, with a particular emphasis on past abdominal surgery by type and measures that can be obtained easily from preoperative imaging. Methods: An institutional review board-approved retrospective review of 258 patients who underwent DIEP flap reconstruction from 2011 through 2020 was performed. Patient demographics, preoperative laboratory studies, and intraoperative factors were appraised. Preoperative computed tomographic angiography or magnetic resonance angiography was used to measure umbilical stalk height (SH), abdominal wall thickness (AWT), and total fascial diastasis. Patients with and without perfusion-related umbilical complications were compared. Results: Forty patients (15.5%) developed umbilical complications, including 20 patients with epidermolysis or scab, 12 with dehiscence, and 14 with partial necrosis. Patients with complications had a significantly higher rate of hypertension, previous abdominal midline incision, more lateral perforators per flap, longer umbilical stalk, and larger SH/AWT ratio (P < 0.05). Logistic regression revealed that SH (P = 0.006) and SH/AWT ratio (P < 0.001) were the only significant predictors, with the latter having a greater area under the receiver operating characteristic curve (area under the curve, 0.79; P < 0.001). Conclusions: Radiographic measurements of umbilical SH and SH/AWT ratio reliably predict the occurrence of umbilical complications, with the ratio having a more robust predictive ability. The authors propose the use of routine preoperative imaging to identify high-risk patients who may benefit from prophylactic measures.
Background: No randomized controlled trials have compared implant and flap reconstruction. Recently, worse longitudinal outcomes have been suggested for flap reconstruction. The authors compared long-term oncologic outcomes of postmastectomy breast reconstruction using propensity score matching. Methods: A retrospective study of postmastectomy reconstruction was achieved using the Weill Cornell Breast Cancer Registry between 1998 and 2019. Patients were matched using propensity scores based on demographic, clinical, and surgical characteristics. Kaplan-Meier estimates, Cox-regression models, and restricted mean survival times (RMST) were used to evaluate patient outcomes. Results: Before matching, 1395 implant and 586 flap patients were analyzed. No difference in overall survival and recurrence were observed. Multivariable models showed decreased survival for Medicare/Medicaid [hazard ratio (HR),
While fat grafting in breast reconstruction continues to grow in popularity, the optimal technique remains elusive and outcomes are varied. This systematic review of available controlled studies utilizing active closed wash and filtration systems (ACWF) sought to examine differences in fat processing efficiency, aesthetic outcomes, and revision rates. A literature search was performed from inception to February 2022 following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) in Ovid MEDLINE (Wolters Kluwer, Alphen aan den Rijn, the Netherlands), Ovid Embase (Wolters Kluwer, Alphen aan den Rijn, the Netherlands), and Cochrane Library (Wiley, Hoboken, NJ). Studies were screened by 2 independent reviewers for eligibility using Covidence screening software. Bibliographies and citing references from selected articles were screened from Scopus (Elsevier, Amsterdam, the Netherlands). The search identified 3476 citations, with 6 studies included. Three studies demonstrated a significantly higher volume of graftable fat harvested in a significantly lower mean grafting time with ACWF than with their respective controls. With respect to adverse events, three studies reported significantly lower incidences of nodule or cyst formation with ACWF with respect to control. Two studies reported a significantly lower incidence of fat necrosis with ACWF vs control, with this trend upheld in 2 additional studies. Three studies reported significantly lower revision rates with ACWF with respect to control. No study reported inferiority with ACWF for any outcome of interest. These data suggest that ACWF yields higher fat volumes in less time than other common techniques, with decreased rates of suboptimal outcomes and revisions, thereby supporting active filtration as a safe and efficacious means of fat processing that may reduce operative times. Further large-scale, randomized trials are needed to definitively demonstrate the above trends.
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