Myth-Busting the DIEP Flap and an Introduction to the Abdominal Perforator Exchange (APEX) Breast Reconstruction Technique: A Single-Surgeon Retrospective Review

DellaCroce, Frank J.; DellaCroce, Hannah; Blum, Craig; Sullivan, Scott K.; Trahan, Christopher; Wise, M. Whitten; Brates, Irena

doi:10.1097/prs.0000000000005484

Cited by 26 publications

(23 citation statements)

References 64 publications

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“…As demonstrated by DellaCroce as well as in our current study, the risk of bulging or hernia is possibly lower than the conventional DIEP technique (DellaCroce et al, 2019). In our study, 41 patients have completed at least 1 year of follow‐up with no record of abdominal wall complications.…”

Section: Discussionsupporting

confidence: 77%

“…According to DellaCroce, pedicle engineering should be used when more than 1 cm of muscle or a motor nerve has to be sacrificed to allow flap elevation with multiple perforators (DellaCroce et al, 2019).…”

Section: Discussionmentioning

confidence: 99%

“…This technique uses the temporary division of the flap vessels to isolate them from the surrounding tissue and then the reconstitution of the pedicle continuum, sparing the entire musculature and relative innervation (http://fplreflib.findlay.co.uk/images/pdf/LBM/lbm2017_brochure.pdf). Recently, DellaCroce has published the final results, summarizing the advantages of this technique and the long‐term patient's outcome (DellaCroce et al, 2019).…”

Section: Introductionmentioning

confidence: 99%

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Abdominal perforator exchange flap (APEX): A classification of pedicle rearrangements

Zoccali

Farhadi

2021

Microsurgery

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Introduction Abdominal‐based reconstruction is the most commonly performed method for breast reconstruction after mastectomy using the patient's own tissues. DIEP flap has allowed to reduce the donor site morbidity but the incidence of bulging or hernia remains still high, especially when flap is based on multiple perforators. Abdominal Perforator Exchange flap (APEX) represents a further step forward in preserving the abdominal wall structures by disassembling the pedicle components and their reconstitution at the end of the dissection. In this study, we explore the possible anatomical configurations of perforators exchange for APEX, providing a simple classification of perforators reconstitution patterns and the possible clinical implications. Materials and methods A retrospective study was conducted on patients who received APEX flap for abdominal based breast reconstruction. Preoperative CT scans and procedure descriptions were analyzed to identify the vascular patterns during flap harvesting and the pedicle reconstitution sites. The onset of abdominal wall and flap related complications were investigated. Results APEX flap was performed on 51 women and four vascular patterns were identified. We identified the Type A pattern in 36 cases (70.6%), the Type B pattern in 8 (15.7%), and the Type C pattern in 5 (9.8%). We performed an extra‐anatomical reanastomosis (Type D) in only two case (3.9%) (p = .09). We recorded anastomotic problems in five pedicles' reconstitution and the odds ratio showed a possible correlation between the localization of pedicle division and the anastomosis problems (p > .05). No total or partial flap loss was recorded during this study. Marginal fat necrosis was clinically observed in three cases, which had very large flaps. No bulging or hernia was recorded. Conclusion Our perforators exchange classification for abdominal‐based flap helps clinician in planning the surgery and also in describing the procedure easily allowing a more efficient communication. This classification could be used to approach perforator flaps with multiple vessels at other anatomical locations as well.

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Section: Discussionsupporting

confidence: 77%

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Abdominal perforator exchange flap (APEX): A classification of pedicle rearrangements

Zoccali

Farhadi

2021

Microsurgery

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“…However, several studies do not report which degree of muscle-sparing surgery they perform during MS fTRAM flap reconstruction. 9 , 13 , 14 , 23 , 26 , 27 As muscle-sparing flap harvest techniques become more popular and new variations are developed, 41 for the sake of accurate outcomes reporting and patient counseling, it is increasingly important for surgeons to adhere to a uniform classification system of muscle wall preservation. DellaCroce et al has expanded on the traditional classification system by offering a specific definition for the point at which muscle transection in the DIEP flap harvest equates to a muscle-sparing fTRAM flap.…”

Section: Discussionmentioning

confidence: 99%

Complications and Patient-reported Outcomes after TRAM and DIEP Flaps: A Systematic Review and Meta-analysis

Eter

Yesantharao

et al. 2020

Plastic and Reconstructive Surgery - Global Open

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Introduction: Transverse rectus abdominis myocutaneous (TRAM) and deep inferior epigastric artery perforator (DIEP) flaps are the most common abdominally based breast reconstruction procedures. Each technique has its advantages and disadvantages; however, how morbidity relates to satisfaction is not well-understood. Our aim was to compare complications and patient-reported outcomes following pedicled TRAM (pTRAM), free TRAM (fTRAM), and DIEP flaps to guide flap selection. Methods: A systematic literature search was conducted, and 2 independent reviewers identified comparative studies of abdominally based flaps. Data were extracted on patient characteristics, complications, and patient-reported outcomes. Meta-analyses were conducted using random effects modeling with the DerSimonian and Laird method. Results: The search retrieved 5090 articles, of which 18 were included in this review. pTRAM flaps trended toward a higher risk of abdominal bulge/hernia compared with DIEP flaps, particularly in low-volume hospitals. While fTRAM flaps had a higher risk of abdominal morbidity compared with DIEP flaps, relative risk decreased when obese patients were excluded and when only muscle-sparing fTRAM flaps were compared. Muscle-sparing flaps had a higher risk of flap loss than fTRAM flaps. Compared with DIEP flaps, pTRAM flaps were associated with lower general satisfaction but comparable emotional well-being. Conclusions: Our findings indicate that safety and satisfaction following abdominally based breast reconstruction depend on flap type and patient characteristics. When possible, DIEP or muscle-sparing fTRAM flaps should be performed for obese patients to decrease the risk of abdominal bulge/hernia. Although pTRAM flaps are associated with a greater risk of flap loss, they are still an appropriate option when microsurgery is not available.

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“…More commonly, the reconstructive surgeon is faced with the decision to either limit the number of perforators, convert to muscle-sparing TRAMs or perform a pedicle disassembly. 10 When faced with such a challenge, we chose to cut the muscle along the tendinous intersection and we found that its substance can withstand repair, limiting the need to sacrifice muscle and avoiding a second micro-anastomosis.…”

Section: Discussionmentioning

confidence: 99%

Intersection-splitting Deep Inferior Epigastric Perforator Flap

Andejani

Althubaiti

2019

Plastic and Reconstructive Surgery - Global Open

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Summary:Preserving a dynamic abdominal wall is the premise behind the evolution of TRAM flaps into deep inferior epigastric perforators (DIEPs). Performing a true DIEP flap requires a highly refined surgical technique and often times involves a tedious intramuscular dissection which may account for the slow, albeit steady adaptation of DIEPs in breast reconstruction. This article intends to address a scenario in which an additional perforator from a different row is needed. Based on our current knowledge of the abdominal wall and its embryology, we propose splitting the rectus abdominis muscle through the intersections while recruiting a second perforator instead of converting the procedure into MS-TRAM or performing a second anastomosis through the perforator exchange technique, APEX. This potentially saves time and simplifies the procedure while maintaining the integrity of the abdominal wall.

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Myth-Busting the DIEP Flap and an Introduction to the Abdominal Perforator Exchange (APEX) Breast Reconstruction Technique: A Single-Surgeon Retrospective Review

Abstract: Supplemental Digital Content is available in the text. This and Related “Classic” Articles Appear on Prsjournal.com for Journal Club Discussions.

Cited by 26 publications

References 64 publications

Abdominal perforator exchange flap (APEX): A classification of pedicle rearrangements

Abdominal perforator exchange flap (APEX): A classification of pedicle rearrangements

Complications and Patient-reported Outcomes after TRAM and DIEP Flaps: A Systematic Review and Meta-analysis

Intersection-splitting Deep Inferior Epigastric Perforator Flap

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