Perforator Characteristics and Impact on Post-operative Outcomes in DIEP Flap Breast Reconstruction: A Systematic Review & Meta-Analysis
Pathik Aravind, MBBS, Shashank Reddy, MD, PhD, Salih Colakoglu, MD, Alexander Sun, MD, MHS
Department of Plastic & Reconstructive, Johns Hopkins University School of Medicine, Baltimore, MD, USA
Background: DIEP flaps are one of, if not the most common technique for autologous breast reconstruction. Despite this, high-quality evidence on perforator selection is lacking and is a subject of continuous debate among plastic surgeons. Thus, we aimed to systematically review the literature to analyze perforators characteristics and their impact on DIEP flap breast reconstruction outcomes.
Methods: We conducted a systematic review and meta-analysis across five databases: ClinicalTrials.gov, Medline, Ovid Embase, PubMed, and Web of Science for all studies on DIEP flap breast reconstruction focused on perforator characteristics – caliber, number, and location. Risk of bias assessment was done using the ROBINS scale. The primary objective was to analyze the impact of perforator characteristics on partial and/or total flap failure and fat necrosis. Data analysis was done using RevMan V5.3.
Results: The initial search gave us 2768 articles of which 17 articles were included. Our study included 3800 patients with 4322 autologous flap reconstructions, of which 3881 (89.8%) were DIEP flaps. Mean age was 48.1 years and mean BMI was 27.8, across studies. Mean follow-up time was 18.6 months (Range=1-107). Overall rate of partial and/or total flap failure was 2.5%, reported in 10 studies. Pooled analysis did not show statistically significant correlation between partial and/or total flap failure and perforator number (OR=1.8, 95% C.I.=0.6-5.1, I2=0%), or perforator location (OR=1.6. 95% C.I.=0.5-4.4, I2=0%). Overall rate of fat necrosis was 12.4% reported across 13 studies. For fat necrosis, initial analysis including all relevant studies also did not show a statistically significant correlation to perforator number (OR=1.7, 95% C.I.=0.8-3.4, I2=78%) or location (OR=1.9, 95%=0.8-4.8, I2=80%). However, there was a high level of heterogeneity in these analyses. Sensitivity analysis accounting for heterogeneity across studies showed that, the odds for fat necrosis was statistically significantly higher when single perforator (OR=2.2, 95% C.I.=1.6-3.1) was used compared to a multiple perforators. Similarly, use of medial row perforators (OR=3.1, 95% C.I.=2.0-4.8) was also seen to be associated with higher odds of fat necrosis compared to lateral row perforators.
Conclusion: Our findings suggest that use of a multiple perforators and lateral row perforators are associated with lower rates of major post-operative complications. Adopting a standardized perforator selection algorithm may facilitate operative decision making, shorten the learning curve for surgeons just starting out and optimize post-operative outcomes by minimizing the burden of major complications. This in turn would help improve patient satisfaction and quality of life.
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