Plastic Surgery Research Council

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Delayed DIEP Flap Loss: A Complication of Microsurgical Advancement and Earlier Discharge
Alicia A. Heelan Gladden, MD, Becky B. Trinh, MD, Alexandra Kovar, MD, Kristen Ohe, BA, Colleen Murphy, MD, Joyce Aycock, MD, David W. Mathes, MD, Tae Chong, MD.
University of Colorado, Aurora, CO, USA.

PURPOSE: The deep inferior epigastric perforator (DIEP) flap has become the preferred option for autologous breast reconstruction. Total flap loss can be a devastating morbidity that results in reoperation, increased cost of care, and decreased patient satisfaction. Traditional teaching is that microvascular complications are most likely to occur in the early post-operative period, typically within 48 hours. The purpose of this study was to investigate DIEP total flap loss at our institution. We hypothesized that most of our institution's flap losses occurred in early post-operative period. METHODS: A retrospective analysis of patients who underwent DIEP flap breast reconstruction at a single academic institution between January 2015 and July 2017 was performed. Three reconstructive microsurgeons performed all procedures. Pre-operative demographic data including oncologic history and post-operative complications were recorded. Delayed flap loss was defined as non-salvageable flap presenting greater than 48 hours after surgery. RESULTS: Eighty-eight patients underwent 137 DIEP flaps for breast reconstruction during the study time-period. Five flaps (3.6%) had threatened flaps due to venous congestion in the first 48 hours post-operatively and three of these were salvaged with emergent operative intervention and anastomotic revision. Five patients suffered total flap loss (3.6%). Sixty percent (3/5) of flap losses occurred after patient discharge (5-6 days post-operatively), with all three patients returning the day after discharge with a non-salvageable flap. All three delayed flap losses were on the left side in patients who underwent bilateral DIEP reconstruction. When patients with early microvascular complications were compared to the delayed flap loss group, there were no significant differences in age, BMI, smoking status, diagnosis of diabetes or hypertension, radiation, or timing of reconstruction (all p>0.05).
CONCLUSION: Over half of our institution's flap losses occurred after patient discharge, greater than 48 hours post-operatively. This finding contradicts the notion that the vast majority of flap losses happen in the immediate post-operative period, most commonly as a result of vascular compromise. The advancement of microsurgical techniques is reducing the frequency of flap loss during this early period, when flaps are closely monitored and prompt revision is possible. We did not identify any specific risk factors for delayed flap loss, though all were left-sided reconstructions. More studies are needed to elucidate the etiology of late flap losses. With greater emphasis on early patient discharge, perhaps more detailed patient education on return precautions is indicated to increase flap salvage rate in this group of patients. <!--EndFragment-->


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