Does surgical procedure type impact postoperative pain and recovery in deep inferior epigastric artery perforator flap breast reconstruction?

Background: The deep inferior epigastric artery perforator (DIEP) flap is the commonest flap used for breast reconstruction after mastectomy. It is performed as a unilateral (based on one [unipedicled] or two [bipedicled] vascular pedicles) or bilateral procedure following unilateral or bilateral mastectomies. No previous studies have comprehensively analyzed analgesia requirements and hospital stay of these three forms of surgical reconstruction. Methods: A 7-year retrospective cohort study (2008–2015) of a single-surgeon’s DIEP-patients was conducted. Patient-reported pain scores, patient-controlled morphine requirements and recovery times were compared using non-parametric statistics and multivariable regression. Results: The study included 135 participants: unilateral unipedicled (n=84), unilateral bipedicled (n=24) and bilateral unipedicled (n=27). Univariate comparison of the three DIEP types showed a significant difference in 12-hour postoperative morphine requirements (P=0.020); bipedicled unilateral patients used significantly less morphine than unipedicled (unilateral) patients at 12 (P=0.005), 24 (P=0.020), and 48 (P=0.046) hours. Multivariable regression comparing these two groups revealed that both reconstruction type and smoking status were significant predictors for 12-hour postoperative morphine usage (P=0.038 and P=0.049, respectively), but only smoking, remained significant at 24 (P=0.010) and 48 (P=0.010) hours. Bilateral reconstruction patients’ mean hospital stay was 2 days longer than either unilateral reconstruction (P<0.001). Conclusions: Although all three forms of DIEP flap breast reconstruction had similar postoperative pain measures, a novel finding of our study was that bipedicled DIEP flap harvest might be associated with lower early postoperative morphine requirements. Bilateral and bipedicled procedures in appropriate patients might therefore be undertaken without significantly increased pain/morbidity compared to unilateral unipedicled reconstructions

Donor site morbidity in DIEP free flap breast reconstructions: A comparison of unilateral, bilateral, and bipedicled surgical procedure types

BACKGROUND: The use of abdominal tissue in post-mastectomy autologous breast reconstruction is a popular choice among reconstructive surgeons. This is the first study to evaluate donor complications comparing unilateral, bilateral, and bipedicled DIEP breast reconstructions. METHODS: A retrospective chart review was conducted of all women undergoing rib-preserving DIEP free flap breast reconstruction at a University Hospital between 2008 and 2015 by the senior surgeon (CMM). RESULTS: A total of 130 patients were included in this study and were divided into three groups: unipedicled unilateral (n = 93), unipedicled bilateral (n = 19), and bipedicled unilateral (n = 18). Relative to the unipedicled unilateral group, the age and BMI-adjusted odds of complication were almost two-fold higher in the bilateral group [Odds ratio (95% CI): 1.97 (0.63, 6.19)] and approximately halved in the bipedicled group [Odds ratio (95% CI): 0.59 (0.22, 1.61)]; however, these associations were not statistically significant. Overall, 75% of complications were managed conservatively. The majority of Clavien-Dindo grade 3 complications were observed in participants from the unipedicled unilateral group (84%), whereas no patients in the bipedicled group developed morbidity that required recourse to surgery or readmission to hospital. CONCLUSIONS: Although further research with greater statistical power will be valuable, the results of this investigation provide evidence that donor site morbidity of bipedicled DIEP free flap breast reconstructions does not increase when compared with those of unipedicled unilateral and unipedicled bilateral surgical procedure types