Floor plan - 2013 Annual Meeting - American Association for Hand ...

DIEP Flaps in Patients with Abdominal Scars: Are Complication Rates Affected?
Institution where the work was prepared: Beth Israel Deaconess Medical Center, Harvard Medical School, Boston,
MA, USA
Brian M. Parrett, MD1; Stephanie A. Caterson, MD2; Adam M. Tobias2; Bernard T. Lee2; (1)Harvard Medical School,
(2)Beth Israel Deaconess Medical Center, Harvard Medical School
Previous abdominal surgery in breast cancer patients is common and may affect perforator anatomy and complication rates in deep
inferior epigastric perforator (DIEP) breast reconstruction patients. The purpose of this study is to determine if preexisting abdominal
scars have an effect on flap and donor site complications in DIEP flap breast reconstruction. Over a 3 year period, DIEP flap patients
were divided into a control group with no preexisting abdominal scars, and a scar group with previous abdominal procedures. Postoperative
flap and donor site complications were retrospectively compared between the two groups with statistical analysis performed
with the chi-square test. Of 168 consecutive DIEP flap patients, 90 patients (54%) underwent 114 DIEP flaps in the control group and 78
patients (46%) underwent 104 flaps in the scar group. The most common previous incisions were the Pfannenstiel, the McBurney's
appendectomy incision, and the midline incision. The mean age was 48 years in both groups. There was no significant difference in BMI
(mean 27 kg/m2 in both groups), smoking history, and radiation status between the two groups. There were no significant differences
in flap loss (1.8% in control vs. 2.9% in scar group), partial flap loss (1.8% vs. 1.0%), or fat necrosis (14.9% vs. 14.4%). However, the scar
group had a significantly higher overall rate of abdominal donor site complications (24.4%) when compared to the control group (6.7%;
p = 0.005). The most common complications in the scar group were abdominal wound breakdown (11.5%), seroma requiring operative
drainage (6.4%), and abdominal laxity or bulge (5.1%). With minor technical modifications, DIEP flaps can be performed successfully
without increased flap complications in patients with preexisting abdominal incisions. However, patients should be informed of an
increased risk for donor site complications.
Laser-Assisted ICG Angiography; Applications in Perforator Flap Surgery
Institution where the work was prepared: Cleveland Clinic Florida, Weston, FL, USA
Michel C. Samson, MD; Martin I. Newman, MD; Cleveland Clinic Florida
BACKGROUND:
The ability to confirm perforator flap perfusion, before harvest and following microsurgical anastomosis, is a key factor in intraoperative
decision-making. Previously, clinical assessment combined with adjuncts such as Doppler ultrasound, temperature probes, and other
modalities have served to provide microsurgeons with clues to perforator flow and flap perfusion. Laser-assisted intraoperative indocyanine
green fluorescent-dye angiography (LA-ICGA) has been used for decades in the diagnosis and treatment of retinal disorders.
Recently, LA-ICGA has been successfully adopted by cardiac, urologic and liver transplant surgeons for its ability to provide unparalleled,
real time vascular images. We report here the initial experience with the application of this technology in perforator flap surgery.
METHODS:
Following IRB approval, LA-ICGA technology was introduced into our perforator flap protocol. In our practice, deep inferior epigastric
perforator flaps are performed for breast reconstruction in breast cancer patients using standard technique. In a prospective fashion,
LA-ICGA was performed prior to harvest and following microsurgical anastomosis. Examined and imaged prior to harvest were the arterial
and venous pedicles as well as the subdermal plexus. Examined and imaged following inset were the arterial and venous anastomoses,
the vascular pedicles and the perfusion of the flaps through both adipose tissue and skin.
RESULTS:
Ten (10) DIEP flaps were performed on eight (8) female breast cancer patients. Flap survival was 100% and one flap (10%) required return
to operating room for venous congestion. LA-ICGA imaging helped to identify intraoperatively: one flap (10%) with inadequate subdermal
plexus perfusion leading us to débride the distal portion of the flap prior to harvest; one flap (10%) with inadequate venous
return leading us to seek additional perforators prior to harvest; and, one flap (10%) in which inadequate perfusion of a mastectomy
flap was identified leading us to débride the marginal tissue prior to final inset.
CONCLUSION:
LA-ICGA appears to be a valuable adjunct in perforator flap surgery. It can be used to evaluate arterial, venous and subdermal plexus
perfusion prior to harvest and following anastomosis. As additional data is collected and analyzed, the ability to interpret findings will
develop. A multicenter trial is recommended to evaluate the effect of this new technology on clinical outcome.
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