Plastic Surgery Research Council
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Presenter: Carolyn L Mulvey, BS
Co-Authors: Cooney CM; Daily FF; Colantuoni E; Ogbuago OU; Cooney DS; Rad AN; Manahan MA; Rosson GD; Sacks JM
Johns Hopkins University School of Medicine

Introduction: Compromised vascular perfusion in autologous breast reconstruction can result in fat necrosis and flap loss. Increased flap weight with fewer perforator vessels may exacerbate imbalances in flap perfusion. We studied deep inferior epigastric perforator (DIEP) and muscle-sparing transverse rectus abdominis myocutaneous (MS-TRAM) flaps in free autologous breast reconstruction to assess the association of fat necrosis, flap weight and perforator number.

Methods: Data from patients who underwent reconstruction with DIEP and/or MS-TRAM flaps between Jan. 1, 2010 - Dec. 31, 2011 (n=123) were retrospectively reviewed. Patient demographics, comorbidities, intraoperative parameters, and post-operative outcomes were collected, including flap fat necrosis and donor/recipient site complications. Logistic regression analysis was used to examine effects of flap weight and perforator number on breast flap fat necrosis.

Results: One hundred twenty-three patients who underwent 179 flaps (166 DIEP, 13 MS-TRAM) were included. Mean flap weight was 658g 289; 132 (73.7%) were single perforator flaps. Thirteen flaps (7.5%) developed fat necrosis. African American patients had increased odds of fat necrosis (odds ratio, OR 11.58, p < 0.001). Odds of developing fat necrosis significantly increased with flap weight (OR 1.5 per 100g increase, p<0.001). In single perforator flaps weighing >1000g, six (42.9%) developed fat necrosis, compared to 14.3% of large multiple perforator flaps.

Conclusions: Flaps with increasing weight have increased risk of fat necrosis. Single perforator flaps >1000g are at highest risk. Perforator flap breast reconstruction can be performed safely; however, considerations concerning race, BMI, deliberate staging with tissue expanders, perforator number and flap weight may potentially optimize outcomes. Although not reaching significance, these data suggest that inclusion of greater than one perforator may decrease odds of fat necrosis in large flaps, thus optimizing free DIEP flap breast reconstruction.

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