Are patients with low body mass index candidates for deep inferior epigastric perforator flaps for unilateral breast reconstruction?

Thin women have not traditionally been considered ideal candidates for autologous breast reconstruction. The purpose of this study was to examine the use of deep inferior epigastric perforator (DIEP) flap reconstruction in thin women undergoing immediate unilateral breast reconstruction. A retrospective review of 1,040 consecutive patients was performed. In total, 381 patients met the inclusion criteria. To improve clinical interpretability, patients were divided into three groups based on body mass index: “thin” (BMI ≤ 22.99), “traditional” (>23 and ≤29.99), and “obese” (BMI >30) candidates. Flap characteristics were compared to mastectomy weights, and postoperative complications were analyzed. In all groups, flap size was generally more than sufficient to match the mastectomy specimen, as flap weight:mastectomy weight ratio ws greater than 1 in all groups with no significant difference between groups (1.1 in thin patients, 1.0 in traditional patients, and 1.0 in obese patients). Fat necrosis prevalence was lowest in the thin group (12.5%), compared to the traditional (15.9%, P = 0.443) or obese (14.4%, P = 0.698) groups. Prevalence of breast infection were lower in the thin patients (5.2%) versus the traditional (8.7%, P = 0.287) or obese (14.4%, P = 0.033). Abdominal wound healing complications and seroma were also lowest in thin patients. DIEP flap breast reconstruction may be an effective method for unilateral breast reconstruction in thin patients, with sufficient flap weights and lower incidence of complications than in heavier patients. As such, low BMI may not present a barrier in the reconstruction of a breast mound matching native breast size. © 2015 Wiley Periodicals, Inc. Microsurgery 35:421–427, 2015.     

Breast reconstruction with TRAM flap after selective embolization of the deep inferior epigastric artery (series of 69 patients)

Vascular complications of the unipedicled TRAM flap pointed out the need for solutions to decrease such occurrences. The flap surgical delay before transfer has been advocated to improve the blood supply but, at the same time, it increases the risk of wound infection at the donor site and imposes a general anesthesia. The DIEP and the free TRAM flap are more complex procedures and need heavy structural resources. Preferential use of the ipsilateral muscular pedicle suggests a lower partial flap necrosis rate. Selective embolization of the deep inferior epigastric arteries prior to surgery realizes an alternative delay and brings a decrease in the vascular complication rate as shown in a study of 40?patients by Scheufler in 2000. We present a series of 69?patients who were reconstructed by means of a delayed pedicled TRAM flap with selective embolization and a predominant use of the ispsilateral pedicle. Sonographic studies performed in 48?patients prior to surgery showed no significative difference in the diameter of the superior epigastic arteries, with or without previous radiotherapy. The mean interval between embolization and surgery was 30?days; the embolization was performed bilateraly in five patients (4?%), and unilaterally in 64?patients (96?%). The mean age of patients was 54?years, radiotherapy was applied in 43?patients (62?%), smoking patients: 11 (16?%), obesity: five (7?%). The ispsilateral pedicled was used in 67?patients (97?%), controlateral pedicle in two patients (3?%). Postoperative flap complications were comprised of partial flap necrosis in two cases (2,9?%), fat necrosis in six cases (8,7?%), impaired wound healing in three cases (4,3?%), abdominal wall weakness in two cases (2,9?%). We compared the present study of ispsilateral delayed pedicled flap to a study from the same authors concerning controlateral pedicled flaps without delay. It has been demonstrated that the complications rate of partial necrosis was divided by four in the first study compared to the second. The preoperative selective embolization of the deep inferior epigastric artery in association with the use of ipsilateral pedicule in TRAM flap decrease the complications rate significatively compared to the controlateral pedicled flap in TRAM flaps.     

The internal mammary artery and vein as recipient vessels for microvascular breast reconstruction: are we burning a future bridge?

Clinical applications for the internal mammary artery include use as an arterial conduit for coronary revascularization and as a recipient artery for microvascular reconstruction of the breast. This study was completed in an attempt to resolve the controversy over which indication should have priority. Five hundred twenty women with breast cancer who underwent breast reconstruction were reviewed. Of these, 240 were 50 years of age or more and were evaluated for cardiac disease. Three components were studied that included analysis of factors related to cardiac function (prior cardiac surgery, specific cardiac disorders, and cardiac medications), analysis of risk factors related to cardiac disease (hypertension, diabetes mellitus, and tobacco use), and analysis of factors related to the reconstruction (selection of recipient vessels, type of reconstruction). The women were stratified based on age-50 to 59 years, 60 to 69 years, and older than 70 years-to analyze trends based on advancing age. Results demonstrated that the incidence of coronary artery disease was 2 in 240 women (0.8%) and that the incidence of factors related to cardiac function and the incidence of risk factors related to cardiac disease appear to increase with advancing age. The internal mammary vessels were used in 35 of 114 free tissue transfers with no adverse sequelae. No woman in whom the internal mammary artery was used has developed coronary artery disease. The 2 women with coronary artery disease were reconstructed with implants. Based on the results of this study, the author thinks that use of the internal mammary artery as a recipient vessel for microvascular reconstruction of the breast is justified. Options for future coronary revascularization would include the opposite internal mammary artery when available, a saphenous vein graft, or angioplasty.