Devastating complication of negative pressure wound therapy after deep inferior epigastric perforator free flap surgery:A case report

BACKGROUND Thermal injuries on free transferred or replanted tissues resulting from loss of sensibility are an infrequent occurrence.They require immediate and appropriate management before they progress to an irreversible condition.Although negative pressure wound therapy(NPWT)can prevent wound progression by increasing microcirculation,the inappropriate application of NPWT on complicationthreatened transferred and replanted tissues can induce an adverse effect.CASE SUMMARY A 48-year-old woman who underwent immediate breast reconstruction with a deep inferior epigastric artery perforator free flap.While applying a heating pad directly to the flap site,she sustained a deep second to third-degree contact burn over 30%of the transferred flap on postoperative 7 d.As the necrotic changes had progressed,we applied an NPWT dressing over the burned area after en-bloc debridement of the transferred tissues on postoperative 21 d.After 4 d of NPWT application,the exposed fatty tissues of the flap changed to dry and browncolored necrotic tissues.Upon further debridement,we noted that the wound gradually reached total necrosis with a collapsed vascular pedicle of deep inferior epigastric artery.CONCLUSION Although NPWT has been shown to be successful for treating various wound types,the significant risk of NPWT application in short-lasting reconstructed flap wounds after thermal injury should be reminded.

Pedicled abdominal flap using deep inferior epigastric artery perforators for forearm reconstruction: A case report

BACKGROUND Pedicled abdominal flaps are a widely used surgical technique for forearm reconstruction in patients with soft tissue defects.However,some drawbacks include restricted flap size,partial flap loss,and donor-site morbidity.To address these concerns,we present a case of a pedicled abdominal flap using the deep inferior epigastric artery perforators(DIEP)for forearm reconstruction in a patient with a large soft tissue defect.CASE SUMMARY A 46-year-old male patient was admitted to our hospital with forearm injury caused by a pressing machine.A 15 cm×10 cm soft tissue defect with complete rupture of the ulnar side structures of the forearm was found.One week after orthopedic management of the neurovascular injury and fractures using the first stage of Masquelet technique,the patient was referred to the plastic and recon-structive surgery department for wound coverage.Surgical debridement and negative-pressure wound therapy revealed a 20 cm×15 cm soft tissue defect.A pedicle abdominal flap with the DIEP was used to cover the defect.Three weeks later,the flap was detached from the abdomen,and the abdominal defect was directly closed.Subsequently,the second stage of Masquelet technique was performed at the fracture site at week 10.Finally,all donor and recipient sites healed without complications,such as flap dehiscence,infection,hematoma,or necrosis.Fracture site osteosynthesis was achieved without complications.CONCLUSION Pedicled abdominal flap using the DIEP provides a reliable option for forearm reconstruction in patients with large soft tissue defects.

Deep inferior epigastric perforator flap for breast reconstruction:experience with 43 flaps

Background In the past decade, there has been increasing breast reconstructions after mastectomy. The ideal material for reconstruction of a breast is fat and skin. The transverse rectus abdominis myocutaneous （TRAM） flap has been the gold standard for breast reconstruction until recently. Abdominal wall function is a major concern for plastic surgeons in breast reconstruction with TRAM flaps. The deep inferior epigastric perforator （DIEP） free flap spares the whole rectus abdominis muscle, includes skin and fat only, and therefore preserves adequate abdominal wall competence. The aim of this study was to summarize our experience in breast reconstruction with DIEP flap. Methods Between March 2000 and August 2005, a total of 43 breast reconstructions were performed on 40 patients by our surgeons using DIEP flap （3 patients had bilateral procedures）, 14 of them were immediate surgeries and 26 were delayed. Abdominal function, satisfaction with the donor site and reconstructed breast, and the sensation recovery was assessed respectively during follow-up. Results The mean age of the patients was 38.6 years （range, 28-50）. The size of the flaps was 11 cm×26 cm in average （height 10-12 cm, width 15-33 cm）. The mean length of the vascular pedicles was 9.3 cm （range, 7-12）. The patients were followed up for a mean of 16 months （range, 6-30 months）. During the follow-up, 2 （5%） patients had total flap loss, 2 （5%） had partial necrosis, 4 （9%） had wound edge necrosis in the abdomen, and 1 had axillary seroma. None of the patients had hernia, and all of them were able to resume their daily activities after the operation. Patient satisfaction with the reconstructed breast rated high, 95% of the patients achieved spontaneous return of sensation in the reconstructed breast, but none of them had a sensation equivalent or approximate to the normal. Conclusions The DIEP flap has the same benefits as the TRAM flap without destroying the continuity of the rectus muscle. It can reduce donor-site morbidity and provide an aesthetic refinement in breast reconstruction.

Simultaneous expander and deep inferior epigastric perforator reconstruction:indications and alloderm sling technique for protecting the anastomosis

Aim:Autologous tissue is considered the“gold standard”for breast reconstruction today.However,little is known about deep inferior epigastric perforator(DIEP)flap reconstruction in combination with tissue expander(TE)/implant.The authors describe a series of combined DIEP flap/TE reconstruction,including its indications and technique to ensure protection of the pedicle during the expansion process.Methods:Between January 2009 and December 2012,patients undergoing immediate DIEP with TE reconstruction were retrospectively reviewed.Oncologic,comorbid conditions,intraoperative,postoperative expansion,complications,and technique data points were collected.Photographs were taken postoperatively and patient’s satisfaction surveys were obtained to assess overall satisfaction.Results:Five patients underwent immediate DIEP flap/TE reconstruction utilizing our alloderm sling technique.There were no complications to the pedicle,flap,expander,or mastectomy skin perioperatively or postoperatively.All patients describe being very satisfied,often with improved breast volume and projection as compared to their preoperative appearance.Conclusion:The results of this study suggest that DIEP flap/TE reconstruction is safe,in particular when utilizing the alloderm sling technique,and should be considered in patients who lack sufficient abdominal tissue,have existing breast asymmetries,or do not desire the scar deformity of latissimus dorsi.

Free deep inferior epigastric perforator flap after abdominal liposuction:reconsidering a contraindication

Autologous breast reconstruction with perforators has been previously avoided in tissues that have undergone liposuction.We present a case series and literature review of breast reconstruction with deep inferior epigastric perforator(DIEP)flaps after abdominal wall liposuction.An MEDLINE search was performed for all relevant articles describing breast reconstruction with DIEP flap technique following the abdominal wall liposuction.Key search words used included“DIEP”,“DIEAP”,“deep inferior epigastric perforator”,“liposuction”and“free flap”.All published data on the topic from 1965 to December 2014 were reviewed.Articles were assessed for reports of clinical cases,complications,age,liposuction amount,time since liposuction and number of perforators for comparison.We have also presented 2 patients who underwent a DIEP procedure with a previous history of liposuction.Eight cases of autologous breast reconstruction using a DIEP flap after liposuction were identified in the literature in addition to the presented cases.The preoperative and postoperative course was uneventful in all cases except one patient who had a mild cellulitis managed with antibiotics and a second patient with a drainable hematoma.The average age was 52 years±6.4 years old,one perforator was used in all cases except one where 2 were used,and the average amount of total liposuction was 1,084 mL.No major complications were reported.Previous liposuction is not an absolute contraindication for free-flap breast reconstruction.Preoperative management should include evaluation of suitable perforators by duplex ultrasound or computed tomography angiography.Larger case series are needed to better understand the safety of perforator flaps after liposuction.

Reconstruction of complex chest wall defects:A case report

BACKGROUND Chronic radiative chest wall ulcers are common in patients undergoing radiation therapy.If not treated early,then symptoms such as erosion,bleeding and infection will appear on the skin.In severe cases,ulcers invade the ribs and pleura,presenting a mortality risk.Small ulcers can be repaired with pedicle flaps.Because radioactive ulcers often invade the thorax,surgeons need to remove large areas of skin and muscle,and sometimes ribs.Repairing large chest wall defects are a challenge for surgeons.CASE SUMMARY A 74-year-old female patient was admitted to our department with chest wall skin ulceration after radiation therapy for left breast cancer.The patient was diagnosed with chronic radioactive ulceration.After multidisciplinary discussion,the authors performed expansive resection of the chest wall ulcers and repaired large chest wall defects using a deep inferior epigastric perforator(DIEP)flap combined with a high-density polyethylene(HDPE)patch.The patient was followed-up 6 mo after the operation.No pigmentation or edema was found in the flap.CONCLUSION DIEP flap plus HDPE patch is one of the better treatments for radiation-induced chest wall ulcers.

A novel approach to achieve breast symmetry in a single-stage procedure

Preservation of the skin envelope and the inframammary fold is the main factor in achieving breast symmetry in unilateral reconstruction.Skin sparing mastectomy(SSM)type-IV followed by immediate autologous reconstruction and contralateral symmetrization permits realizing this goal in large,ptotic breasted patients,and tumor superficially located in the inferior quadrants.If the tumor is superficially located in the superior or inferior quadrants with a previous lumpectomy or quadrantectomy scar in the superior quadrants,modified radical mastectomy and a staged procedure are recommended to avoid poor cosmetic results.Two patients who underwent immediate autologous reconstruction following SSM type-V with contralateral symmetrization in a one-stage procedure are presented.