Breast reconstruction with deep inferior epigastric perforator flaps

Abstract

INTRODUCTIONApproximately 45,000 women are diagnosed with breast cancer in the UK each year. The success of screening and the introduction of adjuvant therapies have meant that prognosis is improving and an increasing number of patients are seeking reconstruction following mastectomy. The purpose of this study was to evaluate the deep inferior epigastric perforator (DIEP) flap reconstructions performed in Stoke Mandeville Hospital and, through analysis of complications, detail the evolution of the current care pathway.METHODSA retrospective analysis was performed of all the DIEP flap reconstructions performed by the senior author (MT) between July 2003 and December 2010.RESULTSOverall, 159 flaps were performed on 141 patients (including 36 bilateral flaps). The average patient age was 49 years (range: 28–70 years) and 13% of flaps were risk reducing for BRCA1/2. Twenty-six per cent of patients suffered one or more complication post-operatively, including systemic complications (pulmonary embolism 2%) and flap specific complications (partial flap necrosis 9%, reanastomosis 3%, fat necrosis 9%). Seventy-four per cent had further elective operations including nipple reconstruction (72%), contralateral breast reduction (36%) and scar revision (21%).CONCLUSIONSDIEP flaps are a safe and reliable option for breast reconstructions. This series illustrates the significant leaning curve, with complications, operative time and ischaemic time reducing through the series and post-operative haemoglobin increasing. The complications experienced in this series of 159 flaps with no total flap loss provide the framework for the evolution of the current care pathway including pre-operative imaging, peri-operative deep vein thrombosis prophylaxis and analgesia.

The DIEP flap breast reconstruction: Starting from scratch in a university hospital

“…This result focuses on a short critical period at the beginning of the practice and confirms the highest level of complication risk [13,14]. In a recent study, Kreymerman et al produced results that contradicted the DIEP learning curve theory [22].…”

“…They succeeded in drastically reducing their complication rate after adopting several technical changes and visiting an external team of experienced surgeons. [14]. In our study, we demonstrated a significant DIEP learning curve regarding three parameters: surgical time, surgical revision rate, and postoperative hospital stay.…”

The appearance of cartilage used in deep inferior epigastric perforator breast reconstruction surgery as a calcified mass on CT scan

“…The perforator vessels from the abdominal flap are anastomosed onto the internal mammary vessels that are approached by removing a small portion of rib. 6 Figure 4 illustrates how the DIEP procedure is performed.…”

Evolving options for breast reconstruction

“…Such complications include not only generic surgical risks including bleeding, infection, and seromas but also procedure-specific complications such as mastectomy flap or abdominal apron necrosis or both and pulmonary injury. Partial fat necrosis in DIEP flaps has been estimated to occur in 9%-17% of patients 89,90 ; however, total flap failure rates have been generally reported to be less than 2% in high-volume centers. 91 Major complications such as pulmonary embolus or death are equally rare.…”