Evidence-Based Clinical Practice Guideline: Autologous Breast Reconstruction with DIEP or Pedicled TRAM Abdominal Flaps

Lee, Bernard T.; Agarwal, Jayant P.; Ascherman, Jeffrey A.; Caterson, Stephanie A.; Gray, Diedra; Hollenbeck, Scott T.; Khan, Seema A.; Loeding, Lauren D.; Mahabir, Raman C.; Miller, Archibald S.; Perdikis, Galen; Schwartz, Jaime; Sieling, Beth A.; Thoma, Achilleas; Wolfman, Judith A.; Wright, Jean L.

doi:10.1097/prs.0000000000003768

Cited by 44 publications

(20 citation statements)

References 20 publications

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“…Breast reconstruction was revolutionized in 1989, when Koshima et al introduced perforator-based reconstruction using the deep inferior epigastric perforator (DIEP) flap [4], thus significantly reducing donor site morbidity whilst at the same time maximizing clinical outcomes and generating aesthetically pleasing results. Since then, the DIEP flap has emerged as a workhorse in reconstructive breast surgery [5][6][7][8][9][10].…”

Section: Introductionmentioning

confidence: 99%

Overall Complication Rates of DIEP Flap Breast Reconstructions in Germany—A Multi-Center Analysis Based on the DGPRÄC Prospective National Online Registry for Microsurgical Breast Reconstructions

Heidekrueger

Moellhoff

Horch

et al. 2021

JCM

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While autologous breast reconstruction has gained momentum over recent years, there is limited data on the structure and quality of care of microsurgical breast reconstruction in Germany. Using the breast reconstruction database established by the German Society of Plastic, Reconstructive and Aesthetic Surgeons (DGPRÄC), the presented study investigated the overall outcomes of deep inferior epigastric perforator (DIEP) flap reconstructions in Germany. Data of 3926 patients and 4577 DIEP flaps performed by 22 centers were included in this study. Demographics, patient characteristics, perioperative details and postoperative outcomes were accounted for. Centers performing < Ø 40 (low-volume (LV)) vs. ≥ Ø 40 (high-volume (HV)) annual DIEP flaps were analyzed separately. Overall, total and partial flap loss rates were as low as 2.0% and 1.1% respectively, and emergent vascular revision surgery was performed in 4.3% of cases. Revision surgery due to wound complications was conducted in 8.3% of all cases. Mean operative time and length of hospital stay was significantly shorter in the HV group (LV: 385.82 min vs. HV: 287.14 min; LV: 9.04 (18.87) days vs. HV: 8.21 (5.04) days; both p < 0.05). The outcome and complication rates deduced from the national registry underline the high standard of microsurgical breast reconstruction on a national level in Germany.

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Section: Introductionmentioning

confidence: 99%

Overall Complication Rates of DIEP Flap Breast Reconstructions in Germany—A Multi-Center Analysis Based on the DGPRÄC Prospective National Online Registry for Microsurgical Breast Reconstructions

Heidekrueger

Moellhoff

Horch

et al. 2021

JCM

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“…The eligibility of patients for free-TRAM/DIEP was based on the judgement of surgeons, preference of patients, and guideline recommendation as a standard-of-care [11]. For NSM, patients should receive standard-of-care physical examination, ultrasound, mammogram and/or MRI assessment of the involved breast.…”

Section: Patients' Eligibilitymentioning

confidence: 99%

The feasibility of nipple-sparing mastectomy in combined with abdominal free flap breast reconstruction without skin paddles for flap monitoring: a single-center experience

Zhu

Chen

et al. 2023

Preprint

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Background Nipple-sparing mastectomy in combination with buried abdominal free flap breast reconstruction without leaving any skin paddles for post-operative monitoring might be associated with better cosmetic outcomes. The feasibility of this approach remains unclear while a detailed and validated protocol of post-operative flap monitoring is lacking. Materials and Methods Eligible patients receiving abdominal free-flap breast reconstruction between 2015 and 2020 in our institution were included. Patients were categorized into the buried-flap cohort and the skin-paddle cohort based on whether a skin paddle remained for direct visual monitoring post-operatively. We reported the learning curve of this surgery and the determinants of operative and/or ischemic time. The oncological outcomes and surgical complications rates were also analyzed. Results This study included 147 eligible patients (buried-flap cohort: N = 18; skin-paddle cohort: N = 129). In early-stage patients with immediate breast reconstruction (N = 104), there were no observed relapse events with a median follow-up time of 18 months. The learning curve analysis showed significant reduction of the surgery time and the ischemic time with accumulation of surgical experience after 30 cases. The surgery time and ischemic time were significantly shorter in the buried flap cohort, when compared to that of the skin-paddle cohort. The take-back surgery rates, flap failure rates, and other complication rates were similar between two cohorts under the intra- and post-operative monitoring protocol. Conclusion This study supported the feasibility of autologous abdominal free-flap breast reconstruction using the buried flap approach, and we validated our intra- and post-operative monitoring protocol. A multicenter and prospective study is needed to validate this approach. Trial registration：NCT05560633

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“…Comorbidities such as hypertension, obesity, coronary artery disease, vasculitis, and diabetes should be carefully considered but do not reflect absolute contraindications. 10 Patients who smoke tobacco should be counseled on the increased risks of mastectomy skin flap necrosis, fat necrosis, flap loss, wound dehiscence, and donor-site complications. 11,12 Patients should be encouraged to quit smoking for at least 4 weeks preceding surgery.…”

Section: Medical Historymentioning

confidence: 99%

A Safe and Efficient Technique for Pedicled TRAM Flap Breast Reconstruction

Semple

Viezel-Mathieu

Al-Shaqsi

et al. 2023

Plastic &Amp; Reconstructive Surgery

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Learning Objectives: After studying this article, the participant should be able to: 1. Understand the indications for a unilateral pedicled transverse rectus abdominis (TRAM) flap-based breast reconstruction. 2. Understand the different types and designs of pedicled TRAM flap used in both immediate and delayed breast reconstruction. 3. Understand the essential landmarks and relevant anatomy of the pedicled TRAM flap. 4. Understand the steps of raising the pedicled TRAM flap, the subcutaneous transfer, and the insetting of the flap on the chest wall. 5. Understand the nature of donor-site management and closure of the defect. 6. Develop a postoperative plan for continuing care and pain management. Summary: This article focuses primarily on the unilateral, ipsilateral pedicled TRAM flap. Although the bilateral pedicled TRAM flap may be a reasonable option in some cases, they have been shown to have a significant impact on abdominal wall strength and integrity. Other types of autogenous flaps using the same lower abdominal tissue, such as a free muscle-sparing TRAM or a deep inferior epigastric flap, can be performed as a bilateral procedure with less impact on the abdominal wall. Breast reconstruction with a pedicled transverse rectus abdominis flap has persisted for decades as a reliable and safe form of autologous breast reconstruction leading to a natural and stable breast shape.

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Evidence-Based Clinical Practice Guideline: Autologous Breast Reconstruction with DIEP or Pedicled TRAM Abdominal Flaps

Cited by 44 publications

References 20 publications

Overall Complication Rates of DIEP Flap Breast Reconstructions in Germany—A Multi-Center Analysis Based on the DGPRÄC Prospective National Online Registry for Microsurgical Breast Reconstructions

Overall Complication Rates of DIEP Flap Breast Reconstructions in Germany—A Multi-Center Analysis Based on the DGPRÄC Prospective National Online Registry for Microsurgical Breast Reconstructions

The feasibility of nipple-sparing mastectomy in combined with abdominal free flap breast reconstruction without skin paddles for flap monitoring: a single-center experience

A Safe and Efficient Technique for Pedicled TRAM Flap Breast Reconstruction

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