CT angiography prior to DIEP flap breast reconstruction: a randomized controlled trial

Colakoğlu, Salih; Tebockhorst, Seth; Freedman, Jonathan; Douglass, Sara; Sıddıkoğlu, Duygu; Chong, Tae W.; Mathes, David W.

doi:10.1016/j.bjps.2021.05.050

Cited by 19 publications

(12 citation statements)

References 27 publications

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“…The efficacy of preoperative CT angiography on reducing operative time has been debated in the literature. 14 21 24 25 All patients in this study had preoperative imaging, and therefore, we are unable to draw conclusions related to effects of CT angiography on operative time from the present study or extrapolate effects to patients without CT angiography. Finally, the findings reported in this study are from a single institution with a high microsurgical volume and relatively low rate of the complications reported.…”

Section: Discussionmentioning

confidence: 82%

Quantifying Complications: An Analysis of Operative Time and Intraoperative Factors in Microsurgical Breast Reconstruction

Egan

Elver

Godbe

et al. 2022

J Reconstr Microsurg

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Background Analysis of operative flow has been shown to improve efficiency in breast microsurgery. Both complex decision-making skills and technical mastery are required to overcome intraoperative challenges encountered during microsurgical reconstruction. Effects of intraoperative complications on operative time have not yet been reported. Methods A retrospective chart review of microsurgical breast reconstructions by three surgeons between 2013–2020 analyzed operative variables and duration. Intraoperative complications were determined from the operative report. Correlations between continuous variables were determined using Spearman correlation coefficients. Nonparametric testing was used when comparing operative duration between groups. Results Operative duration was analyzed for 547 autologous breast reconstruction cases; 210 reconstructions were unilateral and 337 were bilateral. Average operative duration was 471.2 SD 132.2 minutes overall (360.1 SD 100.5 minutes for unilateral cases and 530.5 SD 110.5 minutes for bilateral cases). Operative duration decreased with surgeon experience (r = -0.17, p< .001).Regarding intraoperative complications, difficult donor dissection was correlated with an average operative duration increase of 91.7 minutes (n = 43, 7.9%, p< .001), pedicle injury with an additional 67.7 minutes (n = 19, 3.5%, p = .02) and difficult recipient vessel dissection with an increase of 63.0 minutes (n = 35, 6.4%, p = .003). Complications with anastomosis also showed a statistically significant increase in operative duration, with arterial complications resulting in an increase of 104.3 minutes (n = 41, 7.5%, p< .001) and venous complications resulting in an increase in 78.8 minutes (n = 32, 5.8%, p< .001). Intraoperative thrombus resulted in an increase of 125.5 minutes (n = 20, 3.7%, p< .001), and requiring alternative venous outflow added an average of 193.7 minutes (n = 8, 1.5%, p< .001). Conclusion Intraoperative complications in autologous breast reconstruction significantly increase operative time. The greatest increase in operative time is seen with intraoperative thrombosis or requiring alternative venous outflow. As these complications are rarely encountered in breast microsurgery, opportunities for simulation and case-based practice exist to improve efficiency.

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Section: Discussionmentioning

confidence: 82%

Quantifying Complications: An Analysis of Operative Time and Intraoperative Factors in Microsurgical Breast Reconstruction

Egan

Elver

Godbe

et al. 2022

J Reconstr Microsurg

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“…Pre-operative imaging with CTA allows surgeons to survey the vascular anatomy, identify perforators and plan flap design prior to the operation. Given more effective preoperative planning, operative efficiency has improved, and operation durations decreased (16)(17)(18)(19)(20). More specifically, perforator identification and selection time intraoperatively is significantly shorter if CTA is used pre-operatively to assess the vasculature (21).…”

Section: Editorialmentioning

confidence: 99%

The importance of perioperative team familiarity and its contribution to surgical efficiency and outcomes in microsurgical breast reconstruction

Cevik¹,

Hunter-Smith²,

Rozen³

2023

Gland Surg

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“…Another relatively recent and important aspect in the preoperative planning of DIEP flaps is the ability to assess the vascular architecture of the anterior abdominal wall using computerized tomographic angiography (CTA) or magnetic resonance angiography ( 13 , 14 ). Prior to imaging, most surgeons relied on their intraoperative dissection skills to determine the location and caliber of the perforating vessels.…”

Section: Preoperativementioning

confidence: 99%

“…In addition, the patency and location of the deep inferior epigastric vessels can be demonstrated as type 1 (single vessel), type 2 (double branching pattern), and type 3 (triple branching pattern). In a recent randomized controlled trial focused on CTA versus no CTA, it was demonstrated that preoperative CTA analysis of perforators decreases flap harvest and overall operative time with equivalent postoperative outcomes ( 13 ).…”

Section: Preoperativementioning

confidence: 99%

The deep inferior epigastric perforator flap: where we started and where we are now

Nahabedian¹

2023

Gland Surg

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The deep inferior epigastric perforator (DIEP) flap has been performed since the early 1990s. This represented a significant advancement from the prior autologous options that required removal of all or a portion of various muscle groups. Over the years numerous advancements and modifications have been made to DIEP flap reconstruction that have further facilitated our ability to provide this option following mastectomy. Advancements with preoperative preparation, intraoperative techniques, and postoperative management have served to determine eligibility for DIEP flap reconstruction, improve surgical outcomes, reduce complications, reduce surgical operative time, and facilitate postoperative monitoring. Preoperative advancements have included vascular imaging to identify perforators. Intraoperative advancements have included using the internal mammary perforators as the optimal recipient vessels rather than the thoracodorsal, having a two-team approach with microsurgical reconstruction to reduce operative time and improve outcomes when compared to the single surgeon strategy, using a venous coupler rather than hand sewing the anastomosis, using tissue perfusion technology to determine the perfusion limits within the flap. Postoperative advancements include the use of technology to optimally monitor flaps as well as the use of using enhanced recovery after surgery pathways to improve the postoperative experience and promote early and safe discharge from the hospital. This manuscript will review the evolution of the DIEP flap as it relates to comparing our earlier techniques and strategies compared to our current techniques and strategies following mastectomy and breast reconstruction.

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CT angiography prior to DIEP flap breast reconstruction: a randomized controlled trial

Cited by 19 publications

References 27 publications

Quantifying Complications: An Analysis of Operative Time and Intraoperative Factors in Microsurgical Breast Reconstruction

Quantifying Complications: An Analysis of Operative Time and Intraoperative Factors in Microsurgical Breast Reconstruction

The importance of perioperative team familiarity and its contribution to surgical efficiency and outcomes in microsurgical breast reconstruction

The deep inferior epigastric perforator flap: where we started and where we are now

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