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Learning Objectives: After studying this article, the participant should be able to: 1. Understand the types of abdominally based flaps, their anatomy, and their drawbacks. 2. Understand important aspects of the history and physical examination of patients wishing to undergo these procedures. 3. Understand the benefits of preoperative planning and its role in avoiding complication. 4. Understand the operative steps of the procedures and tips to increase efficiency. 5. Understand the postoperative care of these patients and the role of enhanced recovery pathways., Summary: In this article, the authors review the history, current state, and future directions related to abdominally based microsurgical breast reconstruction. This article covers preoperative, intraoperative, and postoperative considerations intended to improve patient outcomes and prevent complications. Evidence-based findings are reported when available to comprehensively review important aspects of these procedures., (Copyright © 2024 by the American Society of Plastic Surgeons.)

Background: Multiple perforator flap breast reconstruction is an option that avoids implants in selected patients with minimal donor tissue. The technique addresses the need for additional skin to help create a breast envelope with more natural ptosis and additional volume to help create a body-appropriate breast mound while avoiding serial fat grafting. Using four flaps for the reconstruction of two breasts (bilateral stacked flap reconstruction) has recently become feasible with the advancement of microsurgical techniques, increased experience with alternative perforator flaps, and use of co-surgery. In this article, we describe our early experience with bilateral stacked flap breast reconstruction., Methods: From January of 2014 to October of 2018, the senior co-surgeons performed 50 consecutive bilateral stacked flap operations at a single institution. All reconstructions were performed in delayed fashion with a mean operative time of 10 hours. Most breasts (94 percent) were reconstructed with a deep inferior epigastric perforator flap combined with a profunda artery perforator flap. Most flap microanastomoses (91.5 percent) were performed directly with internal mammary vessels. The larger of the two flaps was typically placed inferiorly (66 percent), but there was significant inset variability., Results: Of 200 flaps, five were lost (2.5 percent). Seven take-backs were needed for a flap-related concern, which included two negative explorations and a flap salvage. The most common non-flap-related complication was a thigh wound (17 total, eight requiring a procedure)., Conclusion: The authors' early experience suggests that bilateral stacked flap breast reconstruction is a powerful tool that can be performed with an acceptable microsurgical risk and an acceptable complication profile in highly selected patients., Clinical Question/level of Evidence: Therapeutic, IV., (Copyright © 2020 by the American Society of Plastic Surgeons.)

Background: Neuropathy is a common side effect of chemotherapeutic agents. Manifestations of chemotherapy-induced neuropathy can present in a myriad of fashions, ranging from numbness, tingling, and pain to motor weakness and autonomic dysfunction.1 Given the nature of breast reconstruction, a significant portion of the patients have a history of chemotherapy exposure; its effect on postoperative pain management has not been previously explored., Methods: This study is a retrospective review of patients who underwent deep inferior epigastric perforator flap breast reconstruction performed by the two senior authors from January of 2016 to September of 2019. The patients were separated into two groups, before and after enhanced recovery after surgery. The primary outcome observed was postoperative opioid consumption, measured as oral morphine equivalents; p values were obtained through univariate linear regression., Results: In total, 256 patients were analyzed, of which 113 had chemotherapy exposure. The difference between opioid consumption in patients in the pre-enhanced recovery after surgery group without and with chemotherapy exposure was statistically significant (211.5 mg versus 278.5 mg; p = 0.0279). There was no difference between opioid consumption with regard to chemotherapy history in the enhanced recovery after surgery group (137.4 mg versus 133.0 mg; p = 0.7251)., Conclusions: Patients with chemotherapy exposure required more opioids to be comfortable. It is unknown whether this difference is secondary to increased pain or less effectiveness of opioids. Further research is necessary to assess whether there are better ways to address pain postoperatively in patients with chemotherapy exposure., Clinical Question/level of Evidence: Therapeutic, III., (Copyright © 2020 by the American Society of Plastic Surgeons.)

Background: With advances in technology and technique, the goal of microvascular breast reconstruction has transitioned from flap success to minimizing complications and maximizing aesthetic outcome and efficiency. In an effort to evaluate efficiency, the authors implemented a rigorous process analysis in their practice to evaluate deep inferior epigastric perforator (DIEP) flap breast reconstruction., Methods: A prospective implementation of process analysis was instituted on 147 DIEP flaps. The eight critical maneuvers for a DIEP flap are (1) skin to perforator identification, (2) perforator decision making, (3) perforator dissection, (4) pedicle dissection, (5) flap harvest, (6) preparation for microsurgery, (7) venous anastomosis, and (8) arterial anastomosis. Surgeons with variable experiences (faculty, faculty with senior resident/fellow, and supervised chief resident) used these eight steps to perform DIEP flap reconstruction. The outcomes and time of each maneuver were tracked., Results: The total flap harvest time among the three groups was 54.8 minutes for faculty surgeons, 98.3 minutes for senior resident/fellow working with faculty, and 178.8 minutes for supervised chief resident (p < 0.001). The largest difference was seen in perforator dissection. Increasing the number of perforators resulted in longer flap harvest times. Perforator location did not have an impact on times, but harvesting multiple rows took longer for less experienced surgeons. Body mass index and flap weight did not have an impact on time., Conclusions: The authors share their experience using process analysis for DIEP flap reconstruction. They defined eight critical maneuvers to maximize efficiency and safety. By communicating efficient processes and integrating them into the workflow of a given operation, surgeons can continue to improve throughout the arc of their careers.

Background: As breast reconstructive microsurgeons increase their available flap techniques with experience, the need for stacked and multiple flaps may generate an improved aesthetic outcome. The authors present their institutional experience of using single versus stacked free flap breast reconstruction., Methods: ONE THOUSAND SEVENTY: flaps were performed on 509 patients from 2010 to 2018 by two senior surgeons at a single university hospital. Three hundred eighty-eight flaps were either stacked profunda artery perforator (PAP) flaps, four-flap flaps [bilateral PAP plus bilateral deep inferior epigastric perforator (DIEP) flap], or double-pedicle DIEP/superficial inferior epigastric perforator flaps. Six hundred eighty-two flaps were either unilateral or bilateral DIEP or PAP flap (one flap per breast). Demographics, patient comorbidities, and flap complications were compared between the two groups., Results: Of the 509 patients, 359 underwent single DIEP or PAP flap (one flap per breast) and 150 patients underwent stacked free flaps. The stacked flap group had statistically lower body mass index, higher rates of radiation therapy, longer procedure time, smaller flaps, higher deep venous thrombosis rates, and higher take-back rates compared with the single flap group. There were no statistical differences in the rates of flap loss (2.2 percent in stacked flaps versus 1.1 percent in single flaps), wound complication, hematoma, or pulmonary embolism., Conclusions: Autologous breast reconstruction is the gold standard for natural and durable breast reconstruction, often giving superior aesthetic outcomes and higher patient satisfaction. However, the true success of autologous breast reconstruction is limited to the amount of tissue available to provide total breast reconstruction. This study shows that stacked flap breast reconstruction is safe and has similar complication rates as single-flap breast reconstruction., Clinical Question/level of Evidence: Therapeutic, III.

The success of microvascular reconstruction depends on many factors. Although many factors cannot be dictated by a surgeon, the success of anastomosis can be maximized by honing skill with performing anastomoses. However, size discrepancy of vessels remains a common challenge, given the lack of an ideal technique. In this study, the authors introduce their experience in using composite deep inferior epigastric arterial and venous grafts to overcome the vessel size and pedicle length discrepancy in lateral thigh and superficial inferior epigastric artery (SIEA) flaps. Of the 1095 flaps performed, the authors identified a total of 12 flaps (one lateral thigh flap and 11 SIEA flaps) on nine patients for breast reconstruction. The authors used deep inferior epigastric vessels to act as interposition grafts between the internal mammary artery and flap pedicle. For the SIEA flaps, the authors anastomosed the SIEA system to the deep inferior epigastric arterial system, checked the viability of the flap, and then transferred the flap to the internal mammary artery and flap pedicle. For the SIEA flaps, the authors anastomosed the SIEA system to the deep inferior epigastric arterial system, checked the viability of the flap, and then transferred the flap to the internal mammary artery system in three patients. In the last five patients, the authors anastomosed the deep inferior epigastric vessels to the internal mammary artery system first, and then transferred the SIEA flap. For the lateral thigh flap, the authors anastomosed grafts to the internal mammary artery system first as well. There were no flap losses or fat necrosis. Although the authors' outcomes are limited to only breast reconstruction, they believe this method could be expanded to different types of reconstruction, especially reconstruction of the head and neck.

Introduction: Current research within other surgical specialties suggests that a co-surgeon approach may reduce operative times and complications associated with complex bilateral procedures, possibly leading to improved patient and surgical outcomes. We sought to evaluate the role of the co-surgery team and its development in free flap breast reconstruction., Methods: A retrospective review of free-flap breast reconstruction by two surgeons from 2011 to 2016 was conducted. We analyzed 128 patients who underwent bilateral-DIEP breast. Surgical groups were: single-surgeon reconstruction (SSR; 35 patients), co-surgery where both surgeons are present for entire reconstruction (CSR-I; 69 patients), and co-surgery reconstruction where co-surgeons appropriately assist in two concurrent or staggered cases (CSR-II; 24 patients). Efficiency data collected was OR time and patient length-of-stay (LOS). The rate of flap-failure, return to OR, infection, wound breakdown, seroma, hematoma, and PE/DVT were compared., Results: Single-surgeon reconstruction had significantly longer OR time (678 vs. 485 min, P < .0001), LOS (5 vs. 3.9 days, P < .001), higher wound occurrences of the umbilical site that required surgical correction [11.4 percent (n = 4) vs. 1.5% (n = 1); P < .043] compared to CSR-I. Similarly, SSR had significantly longer average OR time (678 vs. 527 min P < .0001), average LOS (5 vs. 4 days, P = .0005) when compared with CSR-II. There were no total increased patient related complications associated with co-surgery (CSR-I or II)., Conclusion: The addition of a co-surgeon, even with concurrent surgery, reduces operative time, average patient LOS, and postoperative complications. This work lends a strong credence that co-surgery model is associated with increased operative efficiency., (© 2017 Wiley Periodicals, Inc.)

Background: Free tissue transfer to improve bulk and contour in facial deformities has been proven useful, yet refinements that turn an acceptable result into an excellent result are essential to reconstruction. The authors reviewed their experience and described these refinements., Methods: The charts of 371 free tissue transfer cases (1989 to 2010) performed by the senior author (J.W.S.) were reviewed. Free tissue transfer of a circumflex scapular variant flap or superficial inferior epigastric was performed to treat deformities arising from hemifacial atrophy (n = 126), hemifacial microsomia (n = 89), radiation therapy (n = 40), bilateral malformations including lupus and polymyositis (n = 50), other congenital anomalies (n = 25), facial palsy (n = 17), and burns and trauma (n = 24)., Results: Revision surgery planning began at initial flap operation where the flap was stretched maximally and interdigitated with recipient tissue. More tissue was required in the malar region. Revision refinement was indicated in all cases (after 6 months). Flap revision involved liposuction, debulking, reelevation, and release of tethering, followed by tissue rearrangement by means of advancement, rotation, transposition, and/or turnover flaps of subcutaneous tissues from the previous free flap. The jawline frequently required more debulking. Periorbital reconstruction was combined with lower lid support with or without canthal repositioning. Conventional face-lift techniques with the flap as superficial musculoaponeurotic system augmented the result. Autologous fat injection to the alar rim, medial canthus, upper eyelid, and lip was a useful adjunct. Severe lip deficiencies were addressed with local flaps., Conclusion: The keys to improving results were continual critical reassessment, open-mindedness to new approaches, and maintaining high expectations., Clinical Question/level of Evidence: Therapeutic, V.

Great variability exists in microsurgical postoperative care in the United States. Lack of standardized postoperative monitoring protocols and appropriate training of monitoring personnel leads to inefficiency and increased cost of providing microsurgical postoperative care. A 45-question survey was sent to all plastic surgery and plastic surgery-based microsurgery program directors in the United States. Questions focused on the number and type of flaps performed, length of stay, complications, postoperative monitoring setting, training provided to monitoring personnel, and limitations in flap monitoring. The response rate was 31% with 3407 microvascular free flaps performed annually at 26 centers. A total of 1533 flaps were monitored in the intensive care unit (ICU) for an average of 3.1 days. In 45% of responding centers patients were cared for in an ICU secondary to a lack of adequately trained nurses at alternative sites. Printed postoperative protocols were provided to nurses in 39% of centers. With a comparative increase cost of $2878 to $3345 per day for ICU care, this translates into an annual increased cost of $13.7 to $15.9 million to the responding centers. Improved nursing training and the use of standardized postoperative protocols may allow patients to be monitored in non-ICU settings postoperatively, thereby reducing the costs associated with providing postoperative microsurgical care., ((c) Thieme Medical Publishers.)

Microsurgical autologous breast reconstruction (MABR) remains the gold standard technique of breast reconstruction, providing a durable, natural, and aesthetically pleasing result. However, some patients may not be candidates for a traditional deep inferior epigastric perforator (DIEP) flap, either due to abdominal tissue paucity, the need for higher-volume reconstruction, or prior surgical procedures. In these patients, alternative flaps must be considered to achieve the optimal result. Such configurations include the conjoined (or double pedicle) DIEP flap, and alternative flaps such as the lumbar artery perforator (LAP) and profunda artery perforator (PAP) flaps, which can be combined in a stacked fashion. By combining multiple flaps in a conjoined or stacked fashion, breast reconstruction can be optimized to fulfill the three critical components of breast reconstruction in restoring the skin envelope, breast footprint, and conus shape. When harvesting multiple flaps, the surgical sequence of events must be meticulously planned to ensure an efficient and successful operation. Preoperative imaging can aid the surgeon in identifying the ideal perforator, assess for side branches for possible intra-flap anastomoses, expedite the operative time, and decrease intraoperative complications. Reconstructive surgeons should be familiar with the variety of configurations with conjoined and/or stacked flaps to address patient-specific reconstructive needs. [ABSTRACT FROM AUTHOR]

Background  The Enhanced Recovery After Surgery (ERAS) protocol is a multivariate intervention requiring the help of several departments, including anesthesia, nursing, and surgery. This study seeks to observe ERAS compliance rates and obstacles for its implementation at a single academic institution. Methods  This is a retrospective study looking at patients who underwent deep inferior epigastric perforator (DIEP) flap breast reconstruction from January 2016 to September 2019. The ERAS protocol was implemented on select patients early 2017, with patients from 2016 acting as a control. Thirteen points from the protocol were identified and gathered from the patient's electronic medical record (EMR) to evaluate compliance. Results  Two hundred and six patients were eligible for the study, with 67 on the control group. An average of 6.97 components were met in the pre-ERAS group. This number rose to 8.33 by the end of 2017. Compliance peaked with 10.53 components met at the beginning of 2019. The interventions most responsible for this increase were administration of preoperative medications, goal-oriented intraoperative fluid management, and administration of scheduled gabapentin postoperatively. The least met criterion was intraoperative ketamine goal of >0.2 mg/kg/h, with a maximum compliance rate of 8.69% of the time. Conclusion  The introduction of new protocols can take over a year for full implementation. This is especially true for protocols as complex as an ERAS pathway. Even after years of consistent use, compliance gaps remain. Staff-, patient-, or resource-related issues are responsible for these discrepancies. It is important to identify these issues to address them and optimize patient outcomes. [ABSTRACT FROM AUTHOR]

Background  Academic medical centers with large volumes of autologous breast reconstruction afford residents hand-on educational experience in microsurgical techniques. We present our experience with autologous reconstruction (deep inferior epigastric perforators, profunda artery perforator, lumbar artery perforator, bipedicled, and stacked) where a supervised trainee completed the microvascular anastomosis. Methods  Retrospective chart review was performed on 413 flaps (190 patients) with microvascular anastomoses performed by postgraduate year (PGY)-4, PGY-5, PGY-6, PGY-7 (microsurgery fellow), or attending physician (AP). Comorbidities, intra-operative complications, revisions, operative time, ischemia time, return to operating room (OR), and flap losses were compared between training levels. Results  Age and all comorbidities were equivalent between groups. Total operative time was highest for the AP group. Flap ischemia time, return to OR, and intraoperative complication were equivalent between groups. Percentage of flaps requiring at least one revision of the original anastomosis was significantly higher in PGY-4 and AP than in microsurgical fellows: PGY-4 (16%), PGY-5 (12%), PGY-6 (7%), PGY-7 (2.1%), and AP (16%), p  = 0.041. Rates of flap loss were equivalent between groups, with overall flap loss between all groups 2/413 (<1%). Conclusion  With regard to flap loss and microsurgical vessel compromise, lower PGYs did not significantly worsen surgical outcomes for patients. AP had the longest total operative time, likely due to flap selection bias. PGY-4 and AP groups had higher rates of revision of original anastomosis compared with PGY-7, though ultimately these differences did not impact overall operative time, complication rate, or flap losses. Hands-on supervised microsurgical education appears to be both safe for patients, and also an effective way of building technical proficiency in plastic surgery residents. [ABSTRACT FROM AUTHOR]