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

Bodin, F.; Dissaux, C.; Lutz, Jean-Christophe; Hendriks, S.; Fiquet, Caroline; Bruant-Rodier, C.

doi:10.1016/j.anplas.2015.02.005

Cited by 28 publications

(20 citation statements)

References 22 publications

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“…A possible contributing factor to the higher microsurgical reoperation rate in our study is that a significant portion of our primary PMBR procedures took place in the time period between 2002 and 2008 before refinements in microsurgery techniques made these procedures far safer and before a major shift from pedicled to microsurgical reconstruction occurred. [19][20][21] In our study, the rates of unplanned reoperation were over 50% for patients who had immediate microsurgical PMBR The most consistent factor influencing reoperation rate across timing and type of PMBR in our study was the receipt of a previous unplanned reoperation in the same patient (HR: 1.25). A significant proportion of PMBR patients require at least one unplanned reoperation over long-term follow-up and approximately one-quarter of these patients will have three or more reoperations.…”

Section: Discussionsupporting

confidence: 55%

Reoperation cascade in postmastectomy breast reconstruction and its associated factors: Results from a long‐term population‐based study

Roberts

Baxter

Sutradhar

et al. 2020

Journal of Surgical Oncology

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Background: Unplanned surgeries following postmastectomy breast reconstruction (PMBR) may be required to treat complications or to revise the reconstructed breast. The primary objective of this study was to examine factors that influenced unplanned reoperations after PMBR. Methods: A retrospective cohort study using provincial databases in Ontario, Canada, was completed. Patients with breast cancer underwent mastectomy between April 2002 and March 2012 followed by immediate or delayed PMBR. Primary outcome was time from PMBR to unplanned reoperations measured in years. The Anderson-Gill counting process model was used to estimate the risk of recurrent unplanned reoperations over time. Univariate and multivariate analyses were completed to examine the association between covariates. Results: A total of 3066 women underwent PMBR and 51.7% had at least one unplanned reoperation. Unplanned breast reoperation was significantly associated with microsurgical tissue vs implant-based reconstruction (hazard ratio [HR]: 1.27), radiation after PMBR (HR: 1.22), surgery at a nonteaching hospital (HR: 1.16), patient comorbidity score (HR: 1.02), and prior unplanned reoperations (HR: 1.25). Conclusions: Our study provides important long-term population-level data regarding factors influencing unplanned reoperations after PMBR. Patients undergoing microsurgical PMBR or postmastectomy radiation had a higher rate of additional procedures. Every additional reoperation also increases the likelihood of unplanned reoperations resulting in a "reoperation cascade."

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Section: Discussionsupporting

confidence: 55%

Reoperation cascade in postmastectomy breast reconstruction and its associated factors: Results from a long‐term population‐based study

Roberts

Baxter

Sutradhar

et al. 2020

Journal of Surgical Oncology

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“…In addition, there is a learning curve that plastic surgeons should overcome during their early careers. 17,18 Bodin et al reported a substantial drop (from 50 to 6%) in revision rates during this learning curve. 17 Similarly, Hofer et al showed a statistically significant higher revision rate in the first 30 flaps performed by a surgeon.…”

Section: Discussionmentioning

confidence: 90%

“…17,18 Bodin et al reported a substantial drop (from 50 to 6%) in revision rates during this learning curve. 17 Similarly, Hofer et al showed a statistically significant higher revision rate in the first 30 flaps performed by a surgeon. 18 Sando et al evaluated the billing records of 162 patients who underwent postmastectomy implant-based or free flap breast reconstruction.…”

Section: Discussionmentioning

confidence: 90%

Optimizing Outcomes in Free Flap Breast Reconstruction in the Community Hospital Setting: A Stepwise Approach to DIEP/SIEA Flap Procedures with Banking a Hemiabdominal Flap

Okada

Pereira

Montag

et al. 2017

J reconstr Microsurg

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Background Free flap breast reconstruction is a conventional procedure in many countries; however, microvascular compromise remains a devastating outcome. Given the morbidity of total necrosis, optimizing free flap salvage stands out as an important area for research, especially among surgeons to overcome the learning curve period and in resource constrained scenario such as community hospitals. To ensure free deep inferior epigastric perforator (DIEP)/superficial inferior epigastric artery (SIEA) flap breast reconstruction, the authors present a technique involving raising a hemiabdominal flap as a free flap, and banking the remaining flap to be utilized if needed in a subsequent procedure. Methods A retrospective review was performed on all free flap breast reconstructions. In this period, 84 patients (mean age: 50.1 ± 8 years) were included. Results In this study, 65.5% patients underwent immediate reconstruction, and 51.2% received DIEP reconstruction; 9.52% patients were returned to the operating room, and salvage reconstruction using the banked flap was performed in all patients. No differences were observed regarding early complications and age, body mass index, American Society of Anesthesiologists status, diabetes, smoking history, chemotherapy, radiotherapy, and type of flap used (p > 0.05). Hypertension was significantly associated with early complications (p < 0.05). Donor-site complications were associated with RT (p < 0.05). Conclusion The banked flap is a reliable method for ensuring DIEP/SIEA flap survival and should be considered in higher risk reconstructions and community hospitals. We believe that the present technique can be a good addition to the arsenal of plastic surgeons dealing with free flap breast reconstructions in selected patients.

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“…16 Against this background, Cubitt et al showed a plateau of the learning curve after 45 to 100 microsurgical breast reconstructions. 17,18 Many types of research reported on the different training methods for microsurgery and focused on learning curves, reproducibility, or cost of the current learning method. However, even experienced PGYs failed to provide significantly superior results in the performance of the microvascular anastomosis compared with medical students or unexperienced PGY.…”

Section: Discussionmentioning

confidence: 99%

A Structured, Microsurgical Training Curriculum Improves the Outcome in Lower Extremity Reconstruction Free Flap Residency Training: The Ludwigshafen Concept

Kornmann

Xiong

Harhaus

et al. 2020

J Reconstr Microsurg

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Background Risk stratification, economic pressure, and a flat learning curve make the realization and development of proper microsurgical skills and competences a challenging task in the daily clinical practice. In previous studies, we were able to show that microsurgical procedures, e.g., free flaps and replantations, are safe training procedures and teachable in daily clinical practice in view of certain issues of risk stratification. The present study aims to evaluate further improvements in terms of safety and complication rates for free flaps as a training procedure after introduction and continuous implementation of a structured in-house training curriculum for microsurgical skills and competences and a 24-hour free accessible microsurgical training facility for the plastic surgery resident. Methods This retrospective comparative cohort study was conducted to review whether microsurgical skills for free flaps to the lower extremity can further be improved after implementation of the curriculum and a 24-hour accessible training facility. Therefore, we compared cohort A before (2009–2012) and B after (2014–2017) implementation. Patient demographics, procedural characteristics, and outcome parameters for free tissue transfer of the lower extremity were evaluated. Results The comparison of both cohorts showed a significantly reduced postoperative complication rate for cohort B (p <0.05). Furthermore, operation time was shorter, and the hospital stay could be significantly decreased (p <0.01). Workhorse flaps for plastic surgical training were the anterior lateral thigh (ALT) flap or the musculus latissimus dorsi (LD) flap. However, even more complex procedures with arteriovenous loops could be safely performed by plastic surgery residents under the supervision of the senior surgeon in exceptional cases. Conclusion The implementation of a regularly held, microsurgical in-house training curriculum with 24-hour accessible training facility improves procedural and outcome parameters for free flaps to the lower extremity for surgical residents and is an elementary part of skills and competency training. However, risk stratification, repeated surgical exposure, expertise, and institutional infrastructures are essential and must be taken into consideration.

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

Cited by 28 publications

References 22 publications

Reoperation cascade in postmastectomy breast reconstruction and its associated factors: Results from a long‐term population‐based study

Reoperation cascade in postmastectomy breast reconstruction and its associated factors: Results from a long‐term population‐based study

Optimizing Outcomes in Free Flap Breast Reconstruction in the Community Hospital Setting: A Stepwise Approach to DIEP/SIEA Flap Procedures with Banking a Hemiabdominal Flap

A Structured, Microsurgical Training Curriculum Improves the Outcome in Lower Extremity Reconstruction Free Flap Residency Training: The Ludwigshafen Concept

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