38.05 Procedure Type, Post-op Pain, Recovery and Clinical Outcomes in DIEP Flap Breast Reconstruction

Posted on January 18, 2016

A. A. Azizi1,5, A. T. Mohan2,3,4, T. Tomouk5, E. Conci5, E. B. Brickley6, C. M. Malata2,7 1Royal Free Hospital NHS Foundation Trust,London, LONDON, United Kingdom 2Addenbrooke’s University Hospital,Plastic And Reconstructive Surgery Department,Cambridge, CAMBRIDGESHIRE, United Kingdom 3Mayo Clinic,Rochester, MN, USA 4Restoration Of Appearance And Function Charitable Trust (RAFT),Research Fellow,London, LONDON, United Kingdom 5University Of Cambridge,School Of Clinical Medicine,Cambridge, CAMBRIDGESHIRE, United Kingdom 6University Of Cambridge,Department Of Public Health And Primary Care,Cambridge, CAMBRIDGESHIRE, United Kingdom 7Postgraduate Medical Institute At Anglia Ruskin University,Cambridge And Chelmsford, CAMBRIDGESHIRE, United Kingdom

Introduction: Reduced post-operative pain has been shown to decrease complications, accelerate discharge from hospital and improve patient experience. Although perforator flaps can reduce donor site morbidity in comparison to their muscle flap counterparts for breast reconstruction, they are still associated with considerable, local pain which has recently been the subject of various methods of control, such as TAP blocks. There has hitherto been no study of the pain associated with different perforator flap types. We therefore reviewed Deep Inferior Epigastric Artery Perforator (DIEP) flaps used for post-mastectomy breast reconstruction and compared pain and clinical outcomes based on surgical procedure type: unilateral uni-pedicled, unilateral bi-pedicled and bilateral breast reconstructions.

Methods: A 7-year retrospective study (2008-2015) was conducted at a single University Hospital of all women who underwent post-mastectomy DIEP breast reconstruction by as single surgeon using the rib preservation technique for intermammary vessel exposure. Data were collected on patient demographics, operative details, patient pain scores, analgesia requirements, postoperative course and complications. A literature review of pain and morbidity of DIEP breast reconstruction was conducted.

Results:The 177 patients (207 FLAPS) included in the study were categorized into four DIEP groups: unilateral unipedicled (N=85 flaps), unilateral bi-pedicled (N=26 flaps), total unilateral (N=147) and bilateral (N=60 flaps) reconstructions. There were no significant differences in morphine patient controlled analgesic (PCA) requirements over 24 and 48 hours, PCA duration, patient reported pain scores and time to catheter removal across all four groups. Bilateral reconstructions had an increased hospital stay by 2 days (P<0.01). 86% of patients reported their maximum pain scores in the first 24 hours.

Conclusion:This is the first study to compare the clinical outcomes and immediate postoperative morbidity of unipedicled, bipedicled and bilateral DIEP breast reconstructions. PCA requirements, time to catheter removal and pain scores were comparable across all 4 subgroups. Our study showed that there were no clinically significant differences in outcomes between unilateral and bilateral reconstructions or unipedicled against bipedicled unilateral reconstructions attributable to differences in post-operative pain.

38.03 DIEP Free Flap Breast Reconstruction: Review of Impact of Surgical Procedure on Donor Site Morbidity

Posted on January 18, 2016

T. Tomouk1, A. T. Mohan2,3,4, A. Azizi1, E. Conci1, E. B. Brickley5, C. M. Malata2,6 1University Of Cambridge,School Of Clinical Medicine,Cambridge, CAMBRIDGESHIRE, United Kingdom 2Addenbrooke’s University Hospital,Plastic And Reconstructive Surgery Department,Cambridge, CAMBRIDGESHIRE, United Kingdom 3Mayo Clinic,Rochester, MN, USA 4Restoration Of Appearance And Function Charitable Trust (RAFT),Research Fellow,London, LONDON, United Kingdom 5University Of Cambridge,Department Of Public Health And Primary Care,Cambridge, CAMBRIDGESHIRE, United Kingdom 6Postgraduate Medical Institute At Anglia Ruskin University,Cambridge And Chelmsford, CAMBRIDGESHIRE, United Kingdom

Introduction: The use of abdominal tissue in post-mastectomy autologous breast reconstruction is a popular choice among reconstructive surgeons. Abdominal perforator flaps have lower donor site morbidity compared to the Transverse Rectus Abdominis Myocutaneous (TRAM) flap, though complications such as seroma formation, delayed healing, fat necrosis and abdominal wall weakness may still occur. This is the first study to evaluate donor complications based on the type of Deep Inferior Epigastric Artery Perforator (DIEP) surgical procedure and compares unilateral, bilateral and bipedicled breast reconstructions.

Methods: A retrospective chart review was conducted of all women undergoing rib-preserving abdominal free flap breast reconstruction at a University Hospital between 2008-2015 by a single surgeon. Data were collected on patient demographics, operative details and postoperative complications, with a specific focus on donor site morbidity. Patients who underwent Superficial Inferior Epigastric Artery (SIEA) flaps (n=20) or had incomplete information (n=27) were excluded.

Results: Of 177 patients identified, a total of 130 patients (73.4%) were included in this study and divided into three groups for comparison: unilateral (n=93), bilateral (n=19) and bipedicled (n=18). Age, smoking history, radiotherapy and chemotherapy exposure were similar across the three groups and did not influence complication risk. Body Mass Index (BMI) was significantly lower in the bipedicled group, as expected (p<0.01, Kruskal-Wallis test). Wound dehiscence was greatest in the unilateral group at 22.6%, compared to 15.8% in the bilateral, and 5.6% in bipedicled group (p=0.23, Chi-squared Test). Seroma rates were highest in the bilateral group at 63.2% versus 48.4% in the unilateral group and 33.3% in the bipedicled group (p=0.19, Chi-squared Test). Fat necrosis occurred in 12.9% of unilateral, 10.5% of bilateral and 0% of the bipedicled reconstructions. Prevalence of abdominal bulge was low in all three groups (≤6.5%). In univariate analyses and relative to the unipedicled, unilateral group, the overall odds of complication was approximately two-fold higher in the bilateral group (Odds ratio (95% CI): 2.16 (0.66, 7.04)), and almost halved in the bipedicled group (Odds ratio (95% CI): 0.46 (0.17, 1.28)); however these associations had wide confidence intervals and attenuated upon further adjustment. Complications were managed conservatively without recourse to surgery in 68.8%.

Conclusion: DIEP flap breast reconstruction is still fraught with donor site morbidity although most complications are minor and comprise predominantly seroma, delayed healing and fat necrosis. These are often managed conservatively. While bipedicled DIEPs were reserved for lower BMI patients they, like bilateral breast reconstructions, can be performed safely without undue increase in donor site complications. Our study suggests that the type of DIEP flap does not impact donor site morbidity.