Der DIEP Lappen als Standard in der autologen Brustrekonstruktion – Ergebnisse und Algorithmus zur erfolgreichen Rekonstruktion

 

 Permissions and Reprints

Zusammenfassung

Hintergrund: Die autologe Brustrekonstruktion gewinnt zunehmend an Bedeutung insbesondere vor dem Hintergrund der erhöhten Raten an prophylaktischen Mastektomien bei BRCA 1–3 Mutationen. Bezüglich der Indikation und Komplikationsrate zwischen freien DIEP und TRAM Lappenplastiken zur autologen Brustrekonstruktion existieren heterogene Daten.

Material und Methoden: Zwischen Januar 2010 und Dezember 2011 erhielten 362 Patientinnen eine autologe Brustrekonstruktion mittels freier DIEP oder MS-2-TRAM Lappenplastik. Die Wahl der Lappenplastik zwischen DIEP und MS-2-TRAM erfolgte standardisiert durch einen Algorithmus mit präoperativer CT-Angiografie, intraoperativer Lappenperfusionskontrolle und Dopplerdetektion. Die Auswertung berücksichtigte Lappenrandnekrosen <20%, Lappenrandnekrosen >20% und komplette Lappenverluste, Fettnekrosen sowie operative Anastomosenrevisionen.

Ergebnisse: Es wurden bei 362 Patienten 419 freie Lappenplastiken zur Brustrekonstruktion durchgeführt (366 DIEP und 53 MS-2-TRAM). Bei 66 Patientinnen erfolgte eine bilaterale Rekonstruktion (52 Doppel DIEPs, 9 DIEP und MS-2-TRAMS sowie 5 Doppel MS-2-TRAMS). Die totale Lappenverlustrate betrug insgesamt 0,24%. Lappenrandnekrosen <20% zeigten sich bei 0,72 % (DIEP 0,82%, MS-2-TRAM 0%), Lappenrandnekrosen >20% bei 0,72% (DIEP 0,69% MS 2 TRAM 0,98%). Bei einer DIEP Lappenplastik kam es zu einem Totalverlust. Die Rate der Anastomosenrevisionen zeigte sich mit insgesamt 0,48% gering. Es zeigte sich keine signifikant erhöhte Komplikationsrate in einer der Gruppen. Nach Einführung des Algorithmus reduzierte sich der Anteil der MS-2-Tram Lappenplastiken im Vergleich zu dem Zeitraum davor um ca. 20% auf Werte zwischen 10,9–13,5% aller Brustrekonstruktionen.

Schlussfolgerung: Durch die Anwendung des vorgestellten Algorithmus ist die Brustrekonstruktion mit freier DIEP Lappenplastik eine sichere Therapieoption wenn sie hochfrequent in einem mikrochirurgischen Zentrum erfolgt. Die Lappenverlust- und Komplikationsrate ist im Vergleich zu MS-2-Tram nicht erhöht. Die Entscheidung zur Selektion der geeigneten Lappenplastik sollte anhand des vorgestellten Algorithmus erfolgen um ein sicheres reproduzierbares Ergebnis zu erzielen.

Abstract

Background: Autologous breast reconstruction is becoming increasingly important, especially in light of the increased rates of prophylactic mastectomies with BRCA mutations. Regarding the indications and complications between free TRAM and free DIEP flaps for autologous breast reconstruction the current data is not clear.

Materials and Methods: All patients who received an autologous breast reconstruction between January 2010 and January 2014 using free DIEP or free MS-2-TRAM flaps were included in the study. The choice of flap between DIEP and MS-2-TRAM was performed by a standardised algorithm with preoperative CT angiography, intraoperative evaluation of the flap perfusion and Doppler detection. The analysis took into account partial flap necrosis <20% and >20%), complete flap loss, flap necrosis and surgical revision of the anastomosis.

Results: The study considered 362 women who received a total of 419 free flaps for breast reconstruction. 66 patients received a bilateral reconstruction (52 double DIEPS, 9 DIEP and MS2 TRAM and 5 double MS2 TRAMs). The total flap loss was 0.24%. Partial necrosis <20% occurred in 0.72% (DIEP 0.82%, MS2 TRAM 0%), partial necrosis >20% in 0.72% (DIEP 0.69% MS2 TRAM 0.98%). One DIEP flap was lost (0.24%). After implementing our protocol the rate of MS-2-Tram flaps could be reduced to 10–15% of all autologous breast reconstruction procedures as compared to the years before.

Conclusion: Through the application of the presented algorithm for breast reconstruction with free DIEP flap, such surgery is a safe treatment option if it is done at high frequency in a microsurgical centre. Flap loss and complications are not increased compared to MS2 TRAM flaps. The decision for the selection of the appropriate flap for breast reconstruction should be based on the presented algorithm in order to achieve secure and reproducible results.

• Literatur

• 1 Society AC American Cancer Society. Cancer facts and Figures 2013. Atlanta
  PubMed
• 2 Olivari N. The latissimus flap. Br J Plast Surg 1976; 29: 126-128 Available from: http://www.ncbi.nlm.nih.gov/pubmed/776304
  CrossrefPubMedGoogle Scholar
• 3 Allen RJ, Tucker C. Superior gluteal artery perforator free flap for breast reconstruction. Plast Reconstr Surg 1995; 95: 1207-1212 Available from: http://www.ncbi.nlm.nih.gov/pubmed/15988253
  CrossrefPubMedGoogle Scholar
• 4 Allen RJ, Levine JL, Granzow JW. The in-the-crease inferior gluteal artery perforator flap for breast reconstruction. Plast Reconstr Surg 2006; 118: 333-339 Available from: http://www.ncbi.nlm.nih.gov/pubmed/16874198
  CrossrefPubMedGoogle Scholar
• 5 Allen RJ, Haddock NT, Ahn CY et al. Breast reconstruction with the profunda artery perforator flap. Plast Reconstr Surg 2012; 129: 16e-23 e Available from http://www.ncbi.nlm.nih.gov/pubmed/22186541
  CrossrefPubMedGoogle Scholar
• 6 Pelzer M, Reichenberger Ma, Germann G. Microsurgical techniques for breast reconstruction. Chirurg 2011; 82: 807-812 Available from: http://www.ncbi.nlm.nih.gov/pubmed/21845484
  CrossrefPubMedGoogle Scholar
• 7 Koshima I, Soeda S. Inferior epigastric artery skin flaps without rectus abdominis muscle. Br J Plast Surg 1989; 42: 645-648 Available from: http://www.ncbi.nlm.nih.gov/pubmed/2605399
  CrossrefPubMedGoogle Scholar
• 8 Allen R, Treece P. Deep inferior epigastric perforator flap for breast reconstruction. Ann Plast Surg 1994; Available from: http://journals.lww.com/annalsplasticsurgery/Abstract/1994/01000/Deep_Inferior_Epigastric_Perforator_Flap_for.7.aspx
  PubMedGoogle Scholar
• 9 Healy C, Allen RJ. The evolution of perforator flap breast reconstruction: twenty years after the first DIEP flap. J Reconstr Microsurg 2014; 30: 121-125 Available from: http://www.ncbi.nlm.nih.gov/pubmed/24163223
  Article in Thieme ConnectPubMedGoogle Scholar
• 10 Pien I, Caccavale S, Cheung MC et al. Evolving Trends in Autologous Breast Reconstruction: Is the Deep Inferior Epigastric Artery Perforator Flap Taking Over?. Ann Plast Surg 2014; 00 Available from: http://www.ncbi.nlm.nih.gov/pubmed/25180959
  PubMedGoogle Scholar
• 11 Nahabedian MY, Momen B, Galdino G et al. Breast Reconstruction with the free TRAM or DIEP flap: patient selection, choice of flap, and outcome. Plast Reconstr Surg 2002; 110: 466-475 discussion 476–477 Available from: http://www.ncbi.nlm.nih.gov/pubmed/12142662
  CrossrefPubMedGoogle Scholar
• 12 Seidenstuecker K, Munder B, Mahajan AL et al. Morbidity of microsurgical breast reconstruction in patients with comorbid conditions. Plast Reconstr Surg 2011; 127: 1086-1092 Available from: http://www.ncbi.nlm.nih.gov/pubmed/21364411
  CrossrefPubMedGoogle Scholar
• 13 Tran NV, Buchel EW, Convery P. a. Microvascular complications of DIEP flaps. Plast Reconstr Surg 2007; 119: 1397-1405 discussion 1406–1408 Available from: http://www.ncbi.nlm.nih.gov/pubmed/17415232
  CrossrefPubMedGoogle Scholar
• 14 Blondeel PN, Arnstein M, Verstraete K et al. Venous congestion and blood flow in free transverse rectus abdominis myocutaneous and deep inferior epigastric perforator flaps. Plast Reconstr Surg 2000; 106: 1295-1299 Available from: http://www.ncbi.nlm.nih.gov/pubmed/11083558
  CrossrefPubMedGoogle Scholar
• 15 Garvey PB, Buchel EW, Pockaj Ba et al. DIEP and pedicled TRAM flaps: a comparison of outcomes. Plast Reconstr Surg 2006; 117: 1711-1719 discussion 1720–1721 Available from http://www.ncbi.nlm.nih.gov/pubmed/16651940
  CrossrefPubMedGoogle Scholar
• 16 Nahabedian MY, Tsangaris T, Momen B. Breast Reconstruction with the DIEP Flap or the Muscle-Sparing (MS-2) Free TRAM Flap: Is There a Difference?. Plast Reconstr Surg 2005; 115: 436-444 Available from: http://content.wkhealth.com/linkback/openurl?sid=WKPTLP:landingpage&an=00006534-200502000-00010
  CrossrefPubMedGoogle Scholar
• 17 Man L-X, Selber JC, Serletti JM. Abdominal wall following free TRAM or DIEP flap reconstruction: a meta-analysis and critical review. Plast Reconstr Surg 2009; 124: 752-764 Available from: http://www.ncbi.nlm.nih.gov/pubmed/19342994
  CrossrefPubMedGoogle Scholar
• 18 Galanis C, Nguyen P, Koh J et al. Microvascular lifeboats: a stepwise approach to intraoperative venous congestion in DIEP flap breast reconstruction. Plast Reconstr Surg 2014; 134: 20-27 Available from: http://www.ncbi.nlm.nih.gov/pubmed/25028816
  PubMedGoogle Scholar
• 19 Langer S, Munder B, Seidenstuecker K et al. Development of a surgical algorithm and optimized management of complications – based on a review of 706 abdominal free flaps for breast reconstruction. Med Sci Monit 2010; 16: CR518-CR522 Available from: http://www.ncbi.nlm.nih.gov/pubmed/20980954
  PubMedGoogle Scholar
• 20 Lindsey JT. Integrating the DIEP and muscle-sparing (MS-2) free TRAM techniques optimizes surgical outcomes: presentation of an algorithm for microsurgical breast reconstruction based on perforator anatomy. Plast Reconstr Surg 2007; 119: 18-27 Available from: http://www.ncbi.nlm.nih.gov/pubmed/17255652
  CrossrefPubMedGoogle Scholar
• 21 Fansa H, Schirmer S, Frerichs O et al. Stellenwert der CT-Angiografie der Bauchwand für die Planung und Operation von DIEP-, TRAM-und SIEA-Lappenplastiken. Handchir Mikrochir plast Chir 2011; 43: 81-87 Available from: https://www.thieme-connect.com/products/ejournals/abstract/10.1055/s-0030-1262844
  Article in Thieme ConnectPubMedGoogle Scholar
• 22 Kuekrek H, Paepke S, Dobritz M et al. Präoperative CT Angiogriafie zur Planung freier Perforans Lappenplastiken(DIEP Flaps) zur Brustrekonstruktion. Handchir Mikrochir plast Chir 2011; 43: 88-94
  Article in Thieme ConnectPubMedGoogle Scholar
• 23 Hartrampf C. Breast reconstruction with a transverse abdominal island flap. Plast Reconstr 1982; Available from: http://journals.lww.com/plasreconsurg/Abstract/1982/02000/Breast_Reconstruction_with_a_Transverse_Abdominal.6.aspx
  PubMedGoogle Scholar
• 24 Lie KH, Barker AS, Ashton MW. A classification system for partial and complete DIEP flap necrosis based on a review of 17,096 DIEP flaps in 693 articles including analysis of 152 total flap failures. Plast Reconstr Surg 2013; 132: 1401-1408 Available from: http://www.ncbi.nlm.nih.gov/pubmed/24281570
  CrossrefPubMedGoogle Scholar
• 25 Khansa I, Momoh AO, Patel PP et al. Fat necrosis in autologous abdomen-based breast reconstruction: a systematic review. Plast Reconstr Surg 2013; 131: 443-452 Available from: http://www.ncbi.nlm.nih.gov/pubmed/23446559
  CrossrefPubMedGoogle Scholar
• 26 Wurzer P, Spendel S. Besteht ein Unterschied zwischen DIEP-und freiem TRAM-Lappen aus physiologischer und psychologischer Sicht? Eine retrospektive Patientenbefragung. Handchirurgie• … 2014; 256-262 Available from: https://www.thieme-connect.com/products/ejournals/abstract/10.1055/s-0034-1384578
  PubMedGoogle Scholar
• 27 Holm C, Mayr M, Hfter E et al. Perfusion Zones of the DIEP Flap Revisited: A Clinical Study. Plast Reconstr Surg 2006; 117: 37-43 Available from: http://content.wkhealth.com/linkback/openurl?sid=WKPTLP:landingpage&an=00006534-200601000-00006
  CrossrefPubMedGoogle Scholar
• 28 Wong C, Saint-Cyr M, Mojallal A et al. Perforasomes of the DIEP flap: vascular anatomy of the lateral versus medial row perforators and clinical implications. Plast Reconstr Surg 2010; 125: 772-782 Available from: http://www.ncbi.nlm.nih.gov/pubmed/20195105
  CrossrefPubMedGoogle Scholar
• 29 Garvey PB, Clemens MW, Hoy AE et al. Muscle-sparing TRAM flap does not protect breast reconstruction from postmastectomy radiation damage compared with the DIEP flap. Plast Reconstr Surg 2014; 133: 223-233 Available from: http://www.ncbi.nlm.nih.gov/pubmed/24469158
  PubMedGoogle Scholar
• 30 Blondeel PN. Discussion: perfusion-related complications are similar for DIEP and muscle-sparing free TRAM flaps harvested on medial or lateral deep inferior epigastric artery branch perforators for breast reconstruction. Plast Reconstr Surg 2011; 128: 590e-592e Available from: http://www.ncbi.nlm.nih.gov/pubmed/22094756
  CrossrefPubMedGoogle Scholar