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Perfusion-Related Complications are Similar for Abdominal-Based Free Flap Breast Reconstruction Harvested on Medial or Lateral Branch Deep Inferior Epigastric Artery Perforators
Patrick B. Garvey, M.D., Seroos Salavati, BS, Lei Feng, MS, Charles E. Butler, MD.
The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA.
In anatomic studies, the medial branch of the deep inferior epigastric artery (DIEA) appears to perfuse tissue across the midline better than the lateral branch. Thus, harvesting DIEP and MS FTRAM flaps from medial branch DIEA perforators has been recommended for flaps including tissue from the contralateral hemiabdomen. However, it is not known whether the rates of perfusion-related flap complications such as fat necrosis or partial flap necrosis differ between medial versus lateral DIEA branch flaps. We hypothesized that the rates of perfusion-related complications would be lower for unilateral DIEP and MS FTRAM flaps based on medial branch, rather than lateral branch, perforators, especially when tissue from the contralateral hemiabdomen was included in the flap design.
We evaluated 2043 consecutive abdomen-based free flap breast reconstructions performed at The University of Texas MD Anderson Cancer Center between 2000 and 2010. We included only unilateral DIEP or MS FTRAM flaps in which it could be clearly determined from which branch the perforators were harvested. We compared perfusion-related outcomes between flaps harvested exclusively from medial vs. lateral branch perforators. Flap harvest patterns were classified, according to the Holm perfusion zones included with the flap, as hemiflaps (zones 1 & 2), zone 3 flaps (zones 1, 2, & 3), and total flaps (zones 1, 2, 3, & 4). Fat necrosis (palpable firmness ≥ 1 cm present at and beyond 3 months postoperatively) and partial flap necrosis (necrosis of the skin and underlying fat) were determined by physical examination on a regimented follow-up schedule and radiographic and/or pathologic confirmation. Unicovariate and multicovariate regression analysis was used to investigate the effects of patient and reconstruction characteristics on outcomes.
We included 228 patients: 120 (52.6%) medial and 108 (47.4%) lateral branch flaps. Mean follow-up was 30.1 months. Patient characteristics, reconstruction timing, and distribution of DIEP versus MS FTRAM harvest were similar between the two branch groups. The majority of the flaps were zone 3 flaps (79.8%), followed by hemiflaps (15.4%), and total flaps (4.8%). The overall fat necrosis and partial flap necrosis rates were 14.5% and 6.1%, respectively. Multi-covariate logistic regression analysis demonstrated an association between patients with any co-morbidity and the development of fat necrosis (OR=2.88, 95% CI for OR 1.34-6.15; p=0.007) and partial flap necrosis (OR=2.41, 95% CI for OR: 1.18-4.95; p=0.016), but showed medial and lateral branch flaps to have similar rates of fat necrosis (14.3% vs. 20%, respectively; p=0.3719) and partial flap necrosis (7.1% vs. 5.9%, respectively; p=0.7271). MS FTRAM and DIEP fat necrosis (14.5% vs. 18.0%, respectively; p=0.6039) and partial flap necrosis (4.4% vs. 7.5%, respectively; p=0.5576) rates were also similar.
We found rates of clinical perfusion-related complications to be similar in medial and lateral branch flaps. This study is the largest to date comparing perfusion-related outcomes of medial vs. lateral DIEA branch perforator flaps for breast reconstruction. We suggest that surgeons primarily base their decisions regarding DIEA branch harvest on the clinical perfusion quality of the perforators, without overestimating the benefit of medial branch perforator harvest.
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