The value of microvascular breast reconstruction: Cost equivalence of TRAM and DIEP flaps implications in the era of CMS reforms.

BACKGROUND: Recent CMS billing changes have raised concerns about insurance coverage for deep inferior epigastric perforator (DIEP) flap breast reconstruction. This study compared the costs and utilization of transverse rectus abdominis myocutaneous (TRAM), DIEP, and latissimus dorsi (LD) flaps in breast reconstruction. METHOD: The study utilized the National Inpatient Sample database to identify female patients who underwent DIEP, TRAM, and LD flap procedures from 2016 to 2019. Key data such as patient demographics, length of stay, complications, and costs (adjusted to 2021 USD) were analyzed, focusing on differences across the flap types. RESULTS: A total of 17,770 weighted patient encounters were identified, with the median age being 51. The majority underwent DIEP flaps (73.5%), followed by TRAM (14.2%) and LD (12.1%) flaps. The findings revealed that DIEP and TRAM flaps had a similar length of stay (LOS), while LD flaps typically had a shorter LOS. The total hospital charges to costs using cost-to-charge ratio were also comparable between DIEP and TRAM flaps, whereas LD flaps were significantly less expensive. Factors such as income quartile, primary payer of hospitalization, and geographic region significantly influenced flap choice. CONCLUSION: The study's results appear to contradict the prevailing notion that TRAM flaps are more cost-effective than DIEP flaps. The total hospital charges to costs using cost-to-charge ratio and hospital stays associated with TRAM and DIEP flaps were found to be similar. These findings suggest that changes in the insurance landscape, which may limit the use of DIEP flaps, could undermine patient autonomy while not necessarily reducing healthcare costs. Such policy shifts could favor less costly options like the LD flap, potentially altering the landscape of microvascular breast reconstruction.

Breast reconstruction using a superficial inferior epigastric artery flap with pedicle elongation via an arteriovenous loop: A case report.

Superficial inferior epigastric artery (SIEA) flap is often chosen to minimize postoperative complications such as abdominal pain and bulging. However, drawbacks, including a small diameter and a short pedicle, pose challenges in anastomosing or creating the lower pole of the breast. Here, we report a case of breast reconstruction using an SIEA flap with pedicle elongation via an arteriovenous loop (AV-loop) using a contralateral superficial inferior epigastric vein (SIEV) graft. A 49-year-old woman underwent a left total mastectomy with the primary insertion of a tissue expander. Breast reconstruction using an SIEA flap with pedicle elongation was planned. The running pattern, pedicle length, and diameter of bilateral SIEA/SIEV and superficial circumflex iliac artery and vein (SCIA/SCIV) were evaluated preoperatively using a 48-MHz probe of ultra-high-frequency ultrasonography (Vevo MD ultrasound device, Fujifilm Visual Sonics, Amsterdam, the Netherlands). During the flap harvesting, the contralateral SIEV graft was harvested to create an AV-loop for pedicle elongation. The 9 cm graft was anastomosed to the left internal mammary artery and vein (IMA/IMV). After the flap elevation, the created AV-loop was divided at the midpoint and anastomosed to the pedicle of the SIEA flap. The SIEA flap, extended with a SIEV AV-loop, facilitated the augmentation of the lower pole of the breast without the risk of pedicle kinking and pulling. The postoperative course was uneventful, and the patient was discharged on postoperative day 7. The prolonged pedicle length via an AV-loop prevents the pedicle kinking and allows for positioning the flap more freely, resulting in an aesthetically good breast contour by filling in the lower pole. The precise preoperative evaluation of the vessels using ultra-high-frequency ultrasonography facilitated meticulous planning. In cases where surgeons aim to minimize intraoperative and postoperative complications associated with other abdominal free flaps, this method may be considered a viable and promising option.

Inset techniques for the DIEP flap - what improves aesthetic outcomes?

INTRODUCTION: The deep inferior epigastric perforator (DIEP) flap is widely considered as the gold standard in breast reconstruction. The inset technique of the DIEP flap is crucial in determining the overall aesthetic outcome; however, to date no systematic review is available that comprehensively assesses the various techniques. Evaluation of topic: A systematic review was performed according to the PRISMA guidelines. The methodology is outlined within our published protocol (Prospero CRD42023449477). Included articles met a minimal criterion compromising of the intervention (DIEP free flap for breast reconstruction) and outcomes (aesthetic and clinical outcomes). Six articles were included in this review, with a total of 346 patients and a follow-up ranging from 6 months to 4 years. Four articles were of a prospective case series study design, one article was a randomized controlled trial, and one article was a case-control study. The risk of bias was assessed to be high in the case series, but low and moderate in the randomized controlled trial and case-control study respectively. CONCLUSION: Although limited by the quality of the evidence, the single aesthetic unit principle, dual-plane inset, elimination of the need for a skin paddle, appropriate flap positioning and rotation, and algorithmic in-setting may all improve the aesthetic outcome of DIEP free flaps.

'Rosebud' inset of DIEP flap in delayed breast reconstruction for consistent projection, lateral flow, and ptosis.

Here we describe a template of DIEP flap inset that prioritises projection, lateral flow and natural ptosis; key elements of an aesthetically successful delayed breast reconstruction. By not excising the full length of the mastectomy scar, and preserving the scar laterally, we increase the 3-dimensional aesthetic of the breast, moving the final reconstructed breast aesthetic further away from an unintentional 2-dimensional resurfacing. Through controlling the initial take-off around the whole circumference of the breast footprint, a favourable and durable breast conus is consistently achieved. This technique employs designated segments of comparatively more rigid irradiated mastectomy skin flaps, to positively influence reconstructed breast aesthetics at the time of flap inset. Conceptually, this reminds the authors of how the green sepals of a rose shape the bud of petals.

Alternatives to the Gold Standard: A Systematic Review of Profunda Artery Perforator and Lumbar Artery Perforator Flaps for Breast Reconstruction.

INTRODUCTION: Breast reconstruction with the deep inferior epigastric perforator (DIEP) flap is the current gold-standard autologous option. The profunda artery perforator (PAP) and lumbar artery perforator (LAP) flaps have more recently been described as alternatives for patients who are not candidates for a DIEP flap. The aim of this study was to review the survival and complication rates of PAP and LAP flaps, using the DIEP flap as a benchmark. METHODS: A literature search was conducted using PubMed, MEDLINE, Embase, BIOSIS, Web of Science, and Cochrane databases. Papers were screened by title and abstract, and full texts reviewed by three independent blinded reviewers. Quality was assessed using MINORS criteria. RESULTS: Sixty-three studies were included, for a total of 745 PAP, 62 stacked PAP, 187 LAP, and 23,748 DIEP flap breast reconstructions. The PAP (98.3%) had comparable success rate to DIEP (98.4%), and the stacked PAP (88.7%) and LAP (92.5%) success rate was significantly lower (P < 0.0001). The PAP and LAP groups both had a low incidence of fat necrosis. However, the revision rate for the LAP group was 16.1% whereas the PAP group was 3.3%. Donor site wound dehiscence rate was 2.9 in the LAP group and 9.1% in the PAP group. CONCLUSIONS: Profunda artery perforator and DIEP flaps demonstrate very high rates of overall survival. The LAP flap has a lower survival rate. This review highlights the survival and complication rates of these alternative flaps, which may help clinicians in guiding autologous reconstruction technique when a DIEP flap is unavailable.

Continuing Insurance Coverage for Flap-Based Breast Reconstruction: Is There a Reservation Cost Related to a Woman's Abdominal Flap Choice?

BACKGROUND: The recent proposed alterations to the Centers for Medicare and Medicaid Services regulations, although subsequently reversed on August 21, 2023, have engendered persistent concerns regarding the impact of insurance policies on breast reconstruction procedures coverage. This study aimed to identify factors that would influence women's preferences regarding autologous breast reconstruction to better understand the possible consequences of these coverage changes. METHODS: A survey of adult women in the United States was conducted via Amazon Mechanical Turk to assess patient preferences for breast reconstruction options, specifically deep inferior epigastric perforator (DIEP) and transverse rectus abdominis myocutaneous (TRAM) flap surgery. The Cochrane-Armitage test evaluated trends in flap preferences concerning incremental out-of-pocket payment increases. RESULTS: Of 500 total responses, 485 were completed and correctly answered a verification question to ensure adequate attention to the survey, with respondents having a median (interquartile range) age of 26 (25-39) years. When presented with the advantages and disadvantages of DIEP versus TRAM flaps, 78% of respondents preferred DIEP; however, as DIEP's out-of-pocket price incrementally rose, more respondents favored the cheaper TRAM option, with $3804 being the "indifference point" where preferences for both procedures converged (P < 0.001). Notably, respondents with a personal history of breast reconstruction showed a higher preference for DIEP, even at a $10,000 out-of-pocket cost (P = 0.04). CONCLUSIONS: Out-of-pocket cost can significantly influence women's choices for breast reconstruction. These findings encourage a reevaluation of emergent insurance practices that could potentially increase out-of-pocket costs associated with DIEP flaps, to prevent cost from decreasing equitable patient access to most current reconstructive options.

Secondary solution for breast reconstruction following total DIEP flap loss: A single-center experience after 3270 DIEP flaps.

BACKGROUND: Total deep inferior epigastric perforator (DIEP) flap failure is a significant concern in autologous breast reconstruction. Literature on secondary reconstruction options following total flap failure is limited. This study outlines the outcomes of patients who underwent reconstruction post-DIEP flap failure at our institution. METHODS: We conducted a retrospective analysis of patients receiving autologous breast reconstruction between 2004 and 2021. We aimed to identify causes of total DIEP flap failure, outcomes of revision surgery, and outcomes of secondary breast reconstruction procedures. RESULTS: From 2004 to 2021, 3456 free flaps for breast reconstruction were performed, with 3270 being DIEP flaps for 2756 patients. DIEP flap failure was observed in 40 cases (1.22%). Bilateral reconstructions had a higher failure rate (2.31%) than unilateral (0.72%). The primary cause was intraoperative complications during flap harvest (18 cases), followed by insufficient arterial perfusion (seven cases). Other causes included postoperative hematoma (seven cases), venous congestion (six cases), and late-onset fat necrosis (two cases). Post-failure, five patients received a second free flap with three cases of repeated flap failure. Twenty patients received implant-based reconstruction with two cases of reconstruction failure, while seven patients received a pedicled latissimus dorsi (LD) flap reconstructions with no cases of reconstruction failure. Eight patients declined further reconstruction. CONCLUSION: A second free flap post-DIEP failure was associated with a high risk of reconstruction failure, suggesting the need for careful patient selection. Implant-based and pedicled LD flap seem to be reliable secondary reconstruction options.

[Robotic-Assisted DIEP Flap Harvest for Autologous Breast Reconstruction: Case Report, Technical Aspects and Identification of Suitable Patients]. / Die robotisch-assistierte Hebung der DIEP-Lappenplastik zur Brustrekonstruktion: Fallbericht, technische Aspekte und Identifikation geeigneter Patientinnen.

BACKGROUND: Robotic-assisted harvest of the deep inferior epigastric perforator (DIEP) flap is an innovative modification of the traditional open preparation for autologous breast reconstruction. It is assumed that donor-site morbidity (herniae, bulging) is reduced by minimising the fascial incision length in robotic-assisted DIEP flap harvest. MATERIAL & METHODS: This is the first report of a robotic-assisted DIEP harvest in Germany, which was performed in April 2023 at the University Hospital of Freiburg in an interdisciplinary approach of the Departments of Plastic Surgery, Urology and Gynaecology. To determine the value of this novel technique, we assessed the demand by retrospectively performing an analysis of potential patients and conducted a cost analysis based on the breast reconstructions with DIEP flap harvest performed between April 2021 and May 2023 at the Department of Plastic Surgery at Freiburg University Hospital. To this end, we carried out a retrospective analysis of preoperative CT angiographies to determine the proportion of patients suitable for a robotic-assisted procedure in a post-hoc analysis. Furthermore, we describe the basic robotic-assisted techniques and discuss the TEP and TAPP laparoscopic approaches. RESULTS: In line with the previously published literature, a short intramuscular course (≤25 mm) and a perforator diameter of≥1.5 mm and≥2.7 mm (subgroup) were defined as a crucial condition for the robotic-assisted procedure. We analysed 65 DIEP flaps harvested in 51 patients, of which 26 DIEP flaps in 22 patients met both criteria, i. e.≤25 mm intramuscular course and≥1.5 mm diameter of the perforator, while 10 DIEP flaps in 10 patients additionally met the criteria of the subgroup (≥2.7 mm diameter). Based on the intramuscular course of the perforators in the CT angiographies of those 26 DIEP flaps, a potential reduction of the fascial incision of 96.8±25.21 mm (mean±standard deviation) compared with the conventional surgical approach was calculated. The additional material costs in our case were EUR 986.01. However, ischaemia time was 33,5 minutes longer than the median of the comparative cohort. CONCLUSION: The robotic-assisted procedure has already proven to be a feasible alternative in a suitable patient population. However, further studies are needed to confirm that robotic-assisted DIEP flap harvest actually reduces harvest site morbidity and thereby justifies the additional costs and complexity.

Surgical Outcomes of Autologous Breast Reconstruction in Low Body Mass Index Patients: Beyond the Standard DIEP Flap.

BACKGROUND: Autologous breast reconstruction provides higher satisfaction than implant-based reconstruction in women with low body mass index (BMI). However, the accepted standard of microvascular breast reconstruction, the deep inferior epigastric perforator (DIEP) flap, can be challenging to achieve due to the paucity of adnominal bulk in these patients. This study compared operative outcomes in women with BMI less than 23.5 following reconstruction after one of three free flap methods: the DIEP flap, alternative flaps (ie, lumbar artery perforator flap or profounda artery perforator flap), and stacked flaps. METHODS: A retrospective study was conducted on thin patients (BMI <23.5) who underwent autologous breast reconstruction between 2010 and 2021 by two senior authors (N.T.H. and S.S.T.) at a single institution. One hundred fifteen patients were divided into three reconstructive groups. Flap weights, complication rates, secondary revisions, and fat grafting in each group were then compared. RESULTS: The success rate in all three groups was 100%, with only one partial flap loss in the stacked group. There was a significant difference in overall minor complications and donor complications among the three groups, with alternative flaps experiencing the most. All three groups had similar incidences of recipient breast complications, medical complications, need for secondary revisions, and amount of fat grafted. CONCLUSIONS: Autologous breast reconstruction in low BMI patients yields successful and durable results. This study shows that predictable results in the thin patient population can be obtained via alternate autologous methods beyond the standard DIEP flap. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

The triangular prism approximation method for volume estimation of deep inferior epigastric artery perforator flap in breast reconstruction.

BACKGROUND: Many methods to predict the amount of tissue needed for breast reconstruction have been reported, but some require complicated software and special systems. The purpose of this report was to present a simpler method for predicting the volume required for deep inferior epigastric artery perforator (DIEP) flaps. The accuracy of this method was evaluated based on both actual flap design and computed tomography. METHODS: The weight and horizontal (x cm) and vertical (y cm) lengths of the DIEP flap were recorded, and the maximum thickness of subcutaneous tissue (z cm) was measured from computed tomography in 36 cases of breast reconstruction using DIEP flap in our hospital performed between January 2019 and December 2020. Flap volume was calculated using three methods of approximation: triangular prisms using physical and CT measurements (1/2xyz cm3 ); quadrangular and triangular prisms using physical and CT measurements (3/4xyz cm3 ); and a previously reported method using measurements from CT angiography alone and calculation with a standard mathematical formula. These three groups were compared using Bland-Altman plots and intraclass correlation coefficients (ICCs) to assess consistency between predicted and measured values. RESULTS: On Bland-Altman plots, values were distributed almost randomly around the average value of the difference, and no proportional error was evident in the methods. The ICC between predicted and actual values of triangular prisms using physical and CT measurements was largest: ICC (1, 2) = 0.978 (0.825-0.981; 95% confidence interval for ICC). A sufficient flap volume was able to be transplanted in all cases. CONCLUSION: The methods presented appear useful to calculate flap volume closer to the measured value without complicated software systems. These results suggest that the method using two symmetric triangular prisms could predict volume more easily than previously reported methods and may facilitate good breast reconstruction.

The Lumbar Artery Perforator Flap in Breast Reconstruction.

SUMMARY: The lumbar artery perforator flap is a valuable alternative in breast reconstruction whenever the deep inferior epigastric perforator flap is not feasible because of insufficient or unavailable abdominal tissue. The advantage is the ideal shape and consistency of the flap, in addition to the option to perform a nerve anastomosis with the cluneal nerve. The anatomy is consistent, but there are some technical issues related to the short perforator and difficult surgical exposure in the lower back region. The inclusion of a vascular interposition graft improved the authors' results and facilitated their technical challenges and final inset of the flap. These videos guide the surgeon through the different steps involved in a breast reconstruction with the lumbar artery perforator flap.

Unilateral immediate deep inferior epigastric artery perforator flap breast reconstruction following skin sparing mastectomy: A comparative study on revision surgeries to improve breast symmetry.

BACKGROUND: The number of revision surgeries to improve breast asymmetry after deep inferior epigastric perforator (DIEP) flap breast reconstruction is still high worldwide with impact on both patients and healthcare systems. These procedures include fat grafting, contralateral breast symmetrization, scar revision, flap repositioning and remodeling. A previously published DIEP flap insetting algorithm has proven to be effective in selecting patient-tailored strategies to achieve excellent aesthetic outcomes. This study investigated whether this insetting algorithm was effective in reducing revision surgeries in patients undergoing SSM and immediate DIEP flap breast reconstruction to achieve the goal of a one-stage reconstruction. METHODS: This retrospective case-control study included 60 patients (group A) treated without the DIEP flap standardized insetting algorithm and 60 patients (group B) treated with the standardized insetting algorithm, which considers among its variables the type of breast to be reconstructed, abdominal tissue thickness, rotation due to harvesting side. Demographic data, operative data, complications and number of revision surgeries were recorded. RESULTS: One hundred and twenty primary and 106 revision surgeries were performed. Groups were homogenous for age (p = .32), body mass index (p = .77), flap weight (p = .7), operative time (p = .87) and early complications (p = .78). When excluding isolated nipple reconstruction from the revision surgeries, one-stage reconstruction was successfully performed in 26 patients in group A (43.3%) and 39 patients (65.0%) in group B, with a statistically significant difference between the groups (p = .003). CONCLUSIONS: The introduction of a standardized insetting algorithm for immediate unilateral DIEP flap breast reconstruction can be effective in reducing the number of revision surgeries for breast asymmetry, making a one-stage reconstruction an achievable and reliable target.

[Does it Always have to be the Abdomen? Alternative Flaps in Autologous Breast Reconstruction]. / Muss es immer das Abdomen sein? ­ Alternative Lappen zur mikrochirurgischen Brustrekonstruktion.

[English] Deep inferior epigastric artery perforator (DIEP) or muscle-sparing transverse rectus abdominis muscle (ms-TRAM) flaps remain the gold standard for autologous reconstruction in post-mastectomy patients, although many women may not be candidates for abdominally based free tissue transfer. In this scenario, there are several other donor site options based from the thigh (transverse and diagonal upper gracilis flaps, profunda artery perforator flap, lateral thigh flap), trunk (lumbar artery perforator flap), and buttock (superior and inferior gluteal artery perforator flaps). This article will provide insight into the history, relevant anatomy, surgical technique and novel applications (neurotization) for alternative flaps in autologous breast reconstruction.

Stacked TUG and DIEP flaps to reconstruct a single breast: Expanding the scope of autologous breast reconstruction.

When the entire abdominal tissue is inadequate to match the contralateral breast volume and shape or in bilateral cases, the deep inferior epigastric perforator (DIEP) flap alone might not be adequate, even if bipedicled. In such cases, using combinations of donor sites is useful and more effective. We present our series of breast reconstruction using stacked DIEP and transverse upper gracilis (TUG) flaps to achieve better breast volume and shape. Between 2015 and 2021, 7 patients underwent reconstruction with stacked flaps. Three surgical teams performed the surgery simultaneously. Flaps were stacked and shaped on a table; the DIEP was de-epithelised completely and placed upside down with the pedicle anteriorly. A cranial extension of the DIEP pedicle was anastomosed in series to the TUG vessels. The TUG was coned and placed above the DIEP, the skin paddle was used both to create a new nipple-areola complex and for monitoring. The stacked flaps were anastomosed to the recipient vessels and buried under the mastectomy flaps. No flap losses were encountered. The aesthetic outcome was good or excellent and patients considered the surgery as an improvement for their self-appearance. In patients with loose skin and minimal fat, or in bilateral reconstructions, the presented procedure can be considered as a reliable approach to obtain a better breast shape and simultaneously improve body contouring in the donor sites.

Harvesting Composite Arterial and Vein Grafts from Deep Inferior Epigastric Artery and Vein: A Safe Five-Step Method of Preparation.

BACKGROUND: As the use of stacked flaps and options for autologous breast reconstruction increase, the level of complexity in autologous breast reconstruction has risen. Frequently, these reconstruction types present technical challenges such as vessel mismatches and short pedicle length. In this study, the authors introduce their five steps of harvesting composite deep inferior epigastric artery (DIEA) and deep inferior epigastric vein (DIEV) grafts to overcome such challenges. METHODS: The authors performed a retrospective review of patients who underwent microvascular reconstruction using DIEA/DIEV grafts from 2012 to 2020. The grafts were harvested using the five steps, as follows: step 1, a transverse, paramedian skin incision was made at the level of suprapubic crease; step 2, an oblique fasciotomy was made on the lateral rectus border; step 3, DIEA/DIEV vessels were identified and exposed past the confluence of two venae comitantes; step 4, DIEA/DIEV grafts were harvested while sparing motor nerves; and step 5, fascial closure was performed. RESULTS: A total of 40 DIEA/DIEV grafts were used in 25 patients (lumbar artery perforator flaps, n = 25; lateral thigh flaps, n = 1; superficial inferior epigastric artery flaps, n = 12; and flap salvage, n = 2) for breast reconstruction. The average time of harvest was 28 minutes, and there were two flap losses. CONCLUSIONS: In the authors' experience, DIEA/DIEV grafts can be safely harvested and used in flaps with short pedicles and small vessel size. Although the authors' experience was limited to breast reconstruction, the DIEA/DIEV grafts can be used for other types of reconstruction, especially for head and neck reconstruction.

The third dimension in perforator mapping-Comparison of Cinematic Rendering and maximum intensity projection in abdominal-based autologous breast reconstruction.

BACKGROUND: Cinematic Rendering (CR) is a recently introduced post-processing three-dimensional (3D) visualization imaging tool. The aim of this study was to assess its clinical value in the preoperative planning of deep inferior epigastric artery perforator (DIEP) or muscle-sparing transverse rectus abdominis myocutaneous (MS-TRAM) flaps, and to compare it with maximum intensity projection (MIP) images. The study presents the first application of CR for perforator mapping prior to autologous breast reconstruction. METHODS: Two senior surgeons independently analyzed CR and MIP images based on computed tomography angiography (CTA) datasets of 20 patients in terms of vascular pedicle characteristics, the possibility to harvest a DIEP or MS-TRAM flap, and the side of the flap harvest. We calculated inter- and intra-observer agreement in order to examine the accordance of both image techniques. RESULTS: We observed a good inter- and intra-observer agreement concerning the type of flap and the side of the flap harvest. However, the agreement on the pedicle characteristics varies depending on the considered variable. Both investigators identified a significantly higher number of perforators with MIP compared with CR (observer 1, p<0.0001 and observer 2, p<0.0385). CONCLUSION: The current study serves as an explorative study, showing first experiences with CR in abdominal-based autologous breast reconstruction. In addition to MIP images, CR might improve the surgeon's understanding of the individual's anatomy. Future studies are required to compare CR with other 3D visualization tools and its possible effects on operative parameters.