Plastic Surgery Research Council

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Optimizing Perforator Selection: A Comprehensive, Multivariate Analysis of Fat Necrosis and Abdominal Morbidity in DIEP Flap Breast Reconstruction
Austin S. Hembd, M.D., Min-Jeong Cho, M.D., Christopher Venutolo, B.S., Sumeet Teotia, M.D., Nicholas Haddock, M.D..
UT Southwestern Plastic Surgery, Dallas, TX, USA.

Introduction: This study aims to elucidate the important predicting factors for fat necrosis and abdominal morbidity in the patient undergoing DIEP flap reconstruction.

Methods: Retrospective review of 866 free-flap breast reconstructions performed at one institution from 2010-2016. 28 potential predictors were included in multivariable analyses to control for possible confounding interactions.

Results: 409 total DIEA perforator flaps were included in our statistical analysis. 14.4% had flap fat necrosis, 21.3% had an abdominal wound or complication, and 6% had an abdominal bulge or hernia.

Analysis showed an increase in the odds of fat necrosis with increasing flap weight (OR 1.002 per 1g increase, p-value=. 0002). A decrease in the odds of fat necrosis was seen with lateral row (OR .29, p-value=. 001) and both-row perforator flaps (OR .21, p-value=. 001), if ICG angiography was utilized (OR .46, p-value=. 04), and with increasing total flow rate of the flap (OR .62 per 1 mm/s increase, p-value= .05).

Increased odds of abdominal bulge or hernia were seen with lateral or both row perforators (OR 3.21, p-value=. 05) vs. medial row perforator based flaps, and with patients whom had an abdominal wound post-operatively (OR 2.59, p-value=. 05). Returning to the operating room on the initial hospital stay significantly increased the odds of abdominal bulge (OR 5.05, p-value= .01).

There was an increased odds of having abdominal wounds with smoking (OR 1.869, p=.02), hypertension (OR 1.720, p=.04), and increasing flap weight (OR 1.001 per 1g increase, p<.01).

Conclusions: Our results suggest that utilizing larger caliber perforators and perforators from the lateral row alone, or in addition to medial row perforators, can decrease fat necrosis rather than by simply harvesting more perforators alone. However, lateral and both row perforator flaps come at the cost of increasing abdominal bulge rates.

Additionally, we found the use of intra-operative indocyanine green angiography decreased the odds of fat necrosis, while increasing flap weight increased these odds. Larger flaps, smoking, and hypertension led to a higher rate of abdominal wounds. Returning to the OR during the initial hospital stay and abdominal wounds themselves were associated with higher abdominal bulge rates.

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