Scientific Abstract Presentations: Breast 9 Saturday, October 28 Sat, Oct 28 5:00-6:00 p.m. CDT

BACKGROUND: Ptotic breast results from involution of breast parenchyma and laxity of the skin envelope, perceived as an apparent volume loss in the upper pole and the central breast, with the lower pole usually fuller and wider. A variety of techniques of breast reduction and mastopexy treat ptosis and upper pole hollowness, while simultaneously narrowing the lower breast pole and raising the inframammary fold. However, there are several challenges regarding the long-term results in the individual clinical scenarios of diverse chest wall shapes, breast parenchyma quality, fascia and skin laxity, resulting in unpredictable longevity of upper breast fullness. OBJECTIVE: This study focuses on perioperative decision making, several surgical techniques of the autoaugmentation techniques and the breast parenchyma suspension during mammaplasty, for the pleasing long-term aesthetic outcomes of breast shape with narrow cleavage, upper pole fullness and uplifted breast base. RESULTS: For the retrospective series, 250 patients operated by a single surgeon received autoaugmentation and mastopexy or breast reduction. In cases requiring mastopexy, the superior pedicle vertical mammaplasty included autoaugmentation based centrally and inferiorly (type I). In severe cases of breast ptosis, the medially based glandular flap was transposed (type II). In patients undergoing breast reduction with autoaugmentation, island modified flap was described by the author and used (type III). In cases of poor parenchyma quality and high laxity of fascia and skin, Island modified flap and autologous internal bra was described by the author and performed (type IV). Long-term pleasing results of uplifted breasts with narrow medial cleavage, upper pole fullness, correct nipple-areola position, controlled breast volume and youthful lower breast pole were seen, with the mean follow-up of 12 months. Autoaugmentation increased projection, apparent volume of the upper breast pole with optimal cleavage. CONCLUSIONS: The proposed algorithm of 4 types of autoaugmentation techniques designed for diverse range of clinical scenarios has proven to be an effective model for mammaplasty without implants, with consistent results for patients presenting with any grade ptosis and upper pole hollowness. In patients with low-lying, wide breasts who do desire breast augmentation without implant, this recommendations in the study can be employed to deliver patients with a reliably more youthful breast shape.

PURPOSE The 2022 American Society of Plastic Surgeons Clinical Practice Guidelines do not recommend antibiotic prophylaxis following reduction mammaplasty.1 The evidence informing this recommendation is limited and there is a lack of data describing subgroups who are high-risk for surgical site infection (SSI) such as those with elevated body mass index (BMI). Many surgeons continue to routinely prescribe postoperative antibiotics. The purpose of the current study is to compare SSI rates in reduction mammaplasty patients who received postoperative antibiotics and those who did not. The same analysis was also performed for the subgroup of patients with BMI ≥30 kg/m2.

METHODS The 2010-2021 PearlDiver Mariner dataset was reviewed to identify primary encounters for reduction mammaplasty using Current Procedural Terminology code 19318. Patients were confirmed to have received preoperative antibiotics. Exclusion criteria were age 59 years, history of diabetes or smoking, and <90 days of follow up. Age, BMI, and Elixhauser Comorbidity Index (ECI) were tracked.

Patients with postoperative antibiotic use, defined as filling an outpatient antibiotic prescription within 3 days of surgery, were identified and matched 1:1 to patients without postoperative antibiotics based on age and ECI score. Type of prescribed antibiotics were recorded. Ninety-day rates of SSI, emergency department (ED) visits, and readmissions were recorded and compared. Pearson's Chi-squared test was used to compare rates of SSI, ED visits, readmissions, and types of antibiotics prescribed. A subgroup analysis was performed on patients with BMI ≥30 kg/m2.

RESULTS Among patients who also received preoperative antibiotics, 2230 patients who received postoperative antibiotics were identified and matched to 2230 patients who did not. Rates of SSI (1.8% vs 1.7%, p=0.661), ED visits (12.5% vs 11.7%, p=0.435), and readmission (1.8% vs 1.4%, p=0.235) were not statistically different. After filtering for obesity, 218 patients who received postoperative antibiotics were identified and matched to 218 patients who did not. Rates of SSI (1.4% vs 2.8%, p=0.312), ED visits (19.3% vs 15.6%, p=0.313), and readmissions (3.7% vs 0.9%, p=0.055) were not statistically different. First/second generation cephalosporins were the most frequently prescribed antibiotics and prescribed at similar rates between both cohorts (86% and 83%, p=0.127).

CONCLUSIONS The current study found no difference in SSI rates between patients who receive postoperative antibiotics and those who did not. These observations are corroborated in the obese population. While it is important to optimize the postoperative management plan for each patient, surgeons should perform a thoughtful benefit-harm assessment when considering postoperative antibiotics in patients undergoing reduction mammaplasty.

REFERENCES 1. Perdikis G, Dillingham C, Boukovalas S, et al. American Society of Plastic Surgeons Evidence-Based Clinical Practice Guideline Revision: Reduction Mammaplasty. Plast Reconstr Surg. 2022 Mar 1;149(3):392e-409e. doi: 10.1097/PRS.0000000000008860. PMID: 35006204.

Background: Gigantomastia is broadly defined as macromastia requiring a surgical resection of greater than 1500 grams of breast tissue per breast. Patients presenting with gigantomastia can pose significant operative challenges and often are not deemed candidates for reduction mammaplasty as a result of a less favorable risk profile. The Big Easy Breast Reduction (BEBR) is a technique proposed to improve the reliability of reconstructive success for patients with gigantomastia.

Methods: A retrospective review was performed of 115 consecutive patients who underwent reduction mammoplasty for gigantomastia from 2018-2021 by the senior author (J.A.D.), using the BEBR technique. The technique avoids use of a vertical scar, eliminates flap undermining, and employs free nipple grafting. During the study period, the BEBR technique was adopted by a second surgeon (author C.M.R.), for treatment of an additional five patients, including three in the oncoplastic setting. Endpoints including patient demographics, operative times, and complication rates were recorded. Results: The median total specimen weight was 4475g (range 1937-9890g). The average patient BMI was 40.7 (range 26-63.1). Median operative time, measured by total time spent by the patient in the operating room, was 1 hour, 59 minutes. Minor complications occurred in 7 patients (5.8%). There were no occurrences of partial or complete free nipple graft loss. Consistent symmetry and aesthetic outcomes were achieved.

Conclusion: The BEBR technique demonstrates a safe, efficient method for surgical management of gigantomastia, and yields aesthetically pleasing results. The reported series demonstrates the ease of procedure, reproducibility across multiple institutions, and indications.

INTRODUCTION

Fremanezumab is a calcineurin gene-related peptide receptor (CGRP) monoclonal antibody indicated for the preventative treatment of migraine in adults. CGRP is a vasoactive peptide that naturally exists in the trigeminovascular system, but presence of CGRP in the bloodstream causes migraine attacks. CGRP is also critical in the wound healing process by promoting revascularization.

Although biologics have a theoretical risk of post-operative infections and wound healing issues, it is not common clinical practice to stop these medications prior to elective surgical procedures. Here we present a case of severely impaired wound healing following autologous free flap breast reconstruction in a patient treated with fremanezumab.

CASE REPORT

In February 2022, a 48-year-old Caucasian female with a history of chronic migraine (controlled with fremanezumab) presented for consultation for breast reconstruction after testing positive for the BRCA gene. She elected to undergo bilateral prophylactic nipple-sparing mastectomy with muscle-sparing TRAM flap reconstruction in August 2022. Her hospital course was uncomplicated and she was discharged home on post-op day 3 with no immediate wound healing concerns.

Skin necrosis was noted at her first post-operative visit along all incisions. Her wounds continued to evolve with worsening skin necrosis, blistering, and skin sloughing. Topical chemical debridement agents were applied to the compromised skin of the breasts and abdomen. She eventually required sharp debridement of large eschars overlying bilateral breast and abdominal wounds.

The patient was seen in the office weekly over the next six weeks and required additional debridement of her wounds. Continued wound care was recommended to encourage epithelialization of the open wounds. By late December, both breasts had completely healed, and the abdomen had contracted considerably but healed almost completely.

DISCUSSION

We hypothesize that the marked skin necrosis and delayed wound healing seen in this patient may be linked to fremanezumab. It is important to note that she did not have traditional risk factors for poor wound healing such as obesity, smoking, or corticosteroid use. Her treatment with fremanezumab began in May 2021 without interruption of her monthly injections including this elective surgery.

Although relatively new to market, there are currently no official warnings of poor wound healing or increased infection rates with fremanezumab. There is a case report of impaired wound healing after a trivial skin injury with probable association with use of a CGRP receptor antibody.1 However, to our knowledge, there are no reports of impaired wound healing after any surgical procedures in the current literature.

It appears the severely impaired would healing seen in this patient after free flap breast reconstruction can be contributed to her use of fremanezumab. The use of biologic agents for autoimmune or chronic diseases should be taken into consideration when determining perioperative management as the possible risk of delayed wound healing must be weighed against the risk of worsened underlying disease control.

REFERENCES

1. Wurthmann S, Nägel S, Hadaschik E, et al. Impaired wound healing in a migraine patient as a possible side effect of calcitonin gene-related peptide receptor antibody treatment: A case report. Cephalalgia. 2020;40(11):1255-1260. doi:10.1177/0333102420933571.

Purpose: Healthcare systems are shifting towards value-based models where cost-effectiveness of interventions is more important.1 Enhanced Recovery After Surgery (ERAS) pathways are protocols published by the ERAS society for various surgical procedures with evidence-based recommendations on a perioperative care pathway that shortens recovery times while improving cost and clinical efficacy.2,3 Other pathways with similar goals but different interventions are called Enhanced Recovery Pathways (ERP).3 Breast reconstruction is a unique procedure because of the variety of interventions available that can result in large cost variations between patients.4 The purpose of our study was to conduct a systematic review on the cost-effectiveness of ERAS/ERP protocols in abdominally-based autologous breast reconstruction. Further, we reviewed the use of liposomal bupivacaine transversus abdominis plane (TAP) blocks in abdominal autologous reconstruction, focusing on outcomes related to hospital length-of-stay (LOS) and cost.

Methods: PubMed, Embase, Cochrane, Scopus were searched and PRISMA guidelines for systematic reviews were followed. Articles were screened by abstract and full text. Articles were included if full text was available, cost data included, and TAP block was used. Reviews, case reports, and comparisons between immediate and delayed breast reconstruction were excluded. Included articles were reviewed for study-level data highlighting cost of treatment and associated LOS. Cost and LOS were stratified by treatment group (ERAS/ERP vs. non-ERAS/ERP) and postoperative pain control (TAP vs. non-TAP). Incremental cost-effectiveness ratio (ICER) was calculated as the ratio of difference in cost and difference in LOS between treatment and control groups.

Results: Of 381 initial articles, 11 were included. These contained 919 patients, of which 421 participated in an ERAS/ERP pathway. The average ICER for ERAS/ERP pathways was $1664.45 per day (range, $952.70 - $2860). Average LOS of ERAS/ERP pathways was 3.12 days vs. 4.57 days for controls. The average ICER of TAP blocks was $909.19 (range, $89.64 - $1728.73) with an average LOS of 3.70 days for TAP blocks vs. 4.09 days in controls.

Conclusions: The use of ERAS/ERP pathways and postoperative pain control with liposomal bupivacaine TAP block during breast reconstruction is cost-effective and beneficial. These interventions should be included in comprehensive perioperative plans aimed at positive outcomes with reduced costs.

References

1. Teisberg E, Wallace S, O'Hara S. Defining and Implementing Value-Based Health Care: A Strategic Framework. Acad Med. May 2020;95(5):682-685. doi:10.1097/acm.0000000000003122
2. Temple-Oberle C, Shea-Budgell MA, Tan M, et al. Consensus Review of Optimal Perioperative Care in Breast Reconstruction: Enhanced Recovery after Surgery (ERAS) Society Recommendations. Plast Reconstr Surg. May 2017;139(5):1056e-1071e. doi:10.1097/prs.0000000000003242
3. Altman AD, Helpman L, McGee J, et al. Enhanced recovery after surgery: implementing a new standard of surgical care. Cmaj. Apr 29 2019;191(17):E469-e475. doi:10.1503/cmaj.180635
4. Sheckter CC, Matros E, Lee GK, Selber JC, Offodile AC, 2nd. Applying a value-based care framework to post-mastectomy reconstruction. Breast Cancer Res Treat. Jun 2019;175(3):547-551. doi:10.1007/s10549-019-05212-0

Background: The profunda artery perforator (PAP) flap was first introduced as an alternative to the DIEP flap in 2012 (1). and quickly became recognized as a popular secondary option for autologous breast reconstruction. This study aimed to evaluate the detailed anatomical position and characteristics of the PAPs. We also focused on the anatomical relationship between the obturator nerves, which pass the perforators and PAPs. This article may provide readers with a better understanding of the anatomy of the PAPs and donor site morbidities due to nerve injury when harvesting a PAP flap. Methods: In total, nine free cadavers with 18 upper thighs were dissected. Twelve were female, and six were male. The average age was 84.7±4.2 years. Dissection was performed to evaluate the anatomic position and characteristics of perforators from the profunda femoral artery perforators. The perforator distance from the gluteal sulcus, number of perforators, perforating muscles, diameter of the perforators, origin of the perforators, and number of nerves passing above and below the perforators were determined. Results: The average number of perforators that penetrate the adductor magnus muscle was 2.5. The average distance from the origin of the perforators to the gluteal sulcus was 71.72±28.23 mm. The average number of the obturator nerves passing above and below the perforator in the adductor magnus muscle was 1.3 (range, 0–4) and 0.7 (range 0–2), respectively. Conclusions: The data presented in this article provide a detailed anatomic basis for the profunda artery perforator (PAP) flap. The perforators of a PAP flap could possibly be included in a flap with a transverse design. It seems that sacrificing the small obturator nerves during dissection may not lead to significant donor site morbidity.

1. Qian, B., Xiong, L., Li, J., et al. A Systematic Review and Meta-Analysis on Microsurgical Safety and Efficacy of Profunda Artery Perforator Flap in Breast Reconstruction. J Oncol 2019;2019:9506720.

Introduction: Nipple-sparing mastectomy (NSM) allows for complete preservation of the skin envelope but may carry a higher risk of ischemic mastectomy flap or nipple complications. Different implant planes in immediate breast reconstruction (pre-pectoral [PP] or subpectoral [SP]) have different tolerances for ischemic complications though large studies on reconstructive outcomes in NSM are lacking.

Methods: We performed a systematic review of comparative studies in PubMed, EMBASE, and Cochrane databases. In total, 1317 unique articles were identified, of which six met criteria for meta-analysis. Fixed-effects meta-analytic methods were used to compare cohorts when possible; otherwise, pooled averages are reported without statistical comparison.

Results: A total of 1668 reconstructions were included in PP cohorts, and 4023 reconstructions in SP cohorts. Demographics were similar between pooled cohorts, including age (45.1 years in PP vs 46.3 years in SP), BMI (23.3 vs 25.0), and prevalence of neoadjuvant radiotherapy (4.5% vs 6.6%). Mastectomy weight and implant size were also similar, although ADM use was slightly more prevalent in the PP cohort (66.6% vs 55.0%). Pooled rates of capsular contracture were similar between cohorts (PP 4.8% vs SP 3.1%).

Fixed-effects meta-analysis demonstrated a lower rate of mastectomy flap necrosis in the PP cohort (RR 0.24, 95%CI 0.08-0.74). The findings suggested increased rates of infection (RR 1.35, 95%CI 0.95-1.92) and hematoma (RR 1.51, 95%CI 0.44-5.21) in the PP cohort but decreased risk of NAC necrosis (RR 0.75, 95%CI 0.45-1.27), though these did not reach statistical significance. There was no difference in the rate of reconstructive failure (RR 0.95, 95%CI 0.52-1.72).

Conclusions: Rates of mastectomy flap necrosis were lower in prepectoral reconstruction after NSM which may be secondary to selection of this plane only in cases with well-perfused flaps. Rates of other major complications including reconstruction failure are comparable between immediate prepectoral and subpectoral reconstruction after NSM.

Background: Do you have new consultations show up to clinic with multiple comorbidities, high BMI, and lack of medical/nutritional optimization requesting a breast reduction (BBR) at the suggestion of an alternate provider? The purpose of this study is to look at patients in a given year at a single-institution academic center who were inappropriately referred to plastic surgery for breast reduction and to elucidate how these impacts both the patient and the surgeon in regards to time and money.

Methods: A single-institution, two-surgeon retrospective analysis was performed between Jan 2022-Jan 2023. Patients deemed eligible for the study were seen as new consultations at our institution for breast reduction. Patients were separated into cohorts of "appropriate for surgery" and "not appropriate for surgery" on the basis of BMI and comorbidities. Demographics, comorbidities, referring providers, time and cost of the visit lost to the surgeon, distance and time spent driving by the patient, cost to the patient in gas milage, and the conversion rate of patients who came back as suitable candidates for breast reduction were collected and analyzed.

Results: A total of 156 patients were identified who were referred to plastic surgery for breast reduction between Jan 2022-Jan 2023. 40 of these (25%) were denied surgery on the basis of high BMI (>35) or uncontrolled comorbidities. Mean age and BMI at presentation were 36 years (range 16-70) and 30 kg/m2 (range 22.7-48.3). 6 patients (3.8%) referred were active smokers, 18 patients (11.5%) had BMI>35, and 7 patients (4.5%) had uncontrolled diabetes. Of the inappropriate referrals, 65% (26) were from non-surgical subspecialties, 20% (8) were from bariatric surgeons, 10% (4) were from OBGYNs, and 5% (2) were from other various surgical subspecialties. Patients denied surgery drove an average of 42.18 miles (range 10-414) for an average of 98 minutes round-trip (range 20-384). Surgeon's estimated time lost on non-surgical consults ranged between 15-74 minutes with 57.5% (23) reporting 45-60 minutes lost, 20% (8) at 30-44 minutes, 10% (4) at 15-30 minutes, and 5% (2) estimating >60minutes. CPT code 19318 at our institution corresponds to 16.03 + 8 (50%) RVU's per bilateral breast reduction. There was a 5% (2) conversion rate of inappropriately referred patients who were able to control their comorbidities and return to undergo breast reduction, which translates to 913.14 potential RVU's lost across 38 patients.

Conclusion: Many providers refer patients inappropriately to plastic surgery for a multitude of body contouring and breast reduction procedures and many are denied surgery. Very few of these patients return with appropriateness for surgery. The impact of this is significant time and money lost by both the patient, provider, and institution. Our study shows the importance of adhering to general health guidelines, further education on surgical suitability for non-surgical subspecialties, and understanding who an appropriate referral for elective-type surgeries is.

Background: The advantages of restoring the breast after a breast cancer surgery overweight the risk of complications associated with these procedures.1,2 Nowadays, patients undergoing oncological mastectomy have several options to regain their body shape, which will vary according to the patient's characteristics, surgeon preferences, and experience.3 However, some surgical alternatives and patient features have been associated with an increased risk of complications.4,5 The study aims to determine the association between the reconstructive breast technique for obesity and the increased risk of postoperative lymphedema. Methods: On February 2023, anonymized data was extracted from the TriNetX platform, including 20 years from 2000 to 2019. Cohorts were built utilizing the ICD-10, CPT, and TNX-curated codes. The data was analyzed using the platform analytic tools following the data protection laws of the included healthcare organizations. The outcome of interest was postmastectomy lymphedema in mastectomy patients who underwent any form of breast reconstruction compared to those who did not. Results: There were 111,619 mastectomy encounters in the TriNetX database during the 20-year period from the year 2000 to 2019, of which 20,646 (18.5%) underwent reconstruction. The mean age at the index for the cohort was 57.3 years (SD 15.2), and 96% were females. After matching the cohort by age at index, sex, race, axillary lymph node dissection, radiotherapy, chemotherapy, hypertension, diabetes mellitus, congestive heart failure, chronic kidney disease, cellulitis, type of mastectomy procedure, and BMI, patients who underwent reconstructive surgery showed a lower risk of postmastectomy lymphedema (RR 0.903, 95% CI 0.831- 0.98, P= 0.0151). A significant risk reduction was observed with delayed implant-based reconstruction (RR 0.565, 95% CI 0.459- 0.695, P< 0.0001) and free flap reconstruction (RR 0.767, 95% CI 0.627- 0.937, P= 0.0092). No risk reduction associated with immediate implant reconstruction (RR 0.888, 95% CI 0.76- 1.037, P= 0.1339) or TRAM reconstruction (RR 1.583, 95% CI 0.784- 3.197, P= 0.1953) was found. Conclusions: Delayed implant-based and free flap reconstruction is associated with a lower risk of developing postmastectomy lymphedema, while immediate implant-based and TRAM reconstruction is not associated with a similar effect. Future studies should focus on the potential mechanisms of this effect. References 1. Citgez B, Yigit B, Bas S. Oncoplastic and Reconstructive Breast Surgery: A Comprehensive Review. Cureus. Jan 2022;14(1):e21763. doi:10.7759/cureus.21763 2. Macadam SA, Zhong T, Weichman K, et al. Quality of Life and Patient-Reported Outcomes in Breast Cancer Survivors: A Multicenter Comparison of Four Abdominally Based Autologous Reconstruction Methods. Plast Reconstr Surg. Mar 2016;137(3):758-771. doi:10.1097/01.prs.0000479932.11170.8f 3. Weber WP, Shaw J, Pusic A, et al. Oncoplastic breast consortium recommendations for mastectomy and whole breast reconstruction in the setting of post-mastectomy radiation therapy. Breast. Jun 2022;63:123-139. doi:10.1016/j.breast.2022.03.008 4. Shen A, Lu Q, Fu X, et al. Risk factors of unilateral breast cancer-related lymphedema: an updated systematic review and meta-analysis of 84 cohort studies. Support Care Cancer. Dec 14 2022;31(1):18. doi:10.1007/s00520-022-07508-2 5. Matar DY, Wu M, Haug V, Orgill DP, Panayi AC. Surgical complications in immediate and delayed breast reconstruction: A systematic review and meta-analysis. J Plast Reconstr Aesthet Surg. Nov 2022;75(11):4085-4095. doi:10.1016/j.bjps.2022.08.029

Introduction The deep inferior epigastric perforator (DIEP) flap has become the gold standard in autologous reconstruction, although there are inherent risks of donor site morbidities including hernia, bulge and decreased core strength.1 Our previously published data showed a significant decrease in fascial incision length between standard and robotic DIEPs.2 Previous studies have shown that multiple perforators per flap have decreased complications.3 Abdominal perforator exchange (APEX) was introduced in 2019 and further reduced muscle injury while increasing the number of perforators.4 Our aim is to study flap characteristics between standard and robotic DIEPs in terms of number of perforators per flap, average pedicle length, vessel size and number of APEX performed.

Methods A retrospective cohort study was performed for patients who underwent robotic and standard DIEP flap harvest from October 2021 through September 2022. We compared the number of perforators, pedicle length, vessel size and APEX performed for standard versus robotic flaps.

Results 44 robotic and 44 standard flaps were included during the collection period. There was no statistically significant difference in number of perforators (2.5 for standard, 2.0 for robotic for p value of 0.079), pedicle length (13.6 cm for standard, 12.7 cm for robotic for p value of 0.331) and vessel size (artery 2.71 mm for standard versus 2.77 mm for robotic for p value of 0.424, vein 3.37 mm for standard versus 3.58 mm for robotic for p value of 0.067). The number of APEX performed in the standard DIEP were 4 compared to 12 on the robotic side (p value of 0.032). There were no pedicle injuries in either group and no flap losses. There were two takebacks in the standard group and one in the robotic group (p value of 1.00).

Conclusion As robotic assisted harvest of the DIEP becomes more common, we show no difference in flap characteristics between the two groups in term of number of perforators, pedicle length or vessel size. In order to increase the number of perforators in the robotic group, there were more APEX performed, which does increase the complexity of the case without any compromise in safety.

References 1. EA Bailey and SN Bishop. (2023). Minimally Invasive Surgery in Breast Reconstruction: The Past and Future. Breast Cancer Updates [Working Title]. Doi: 10.5772/intechopen.109503 2. EA Bailey, B Chen, W Nelson, S Nosik, R Fortunato, A Moreira, D Murariu. Robotic versus Standard Harvest of Deep Inferior Epigastric Artery Perforator Flaps: Early Outcomes. PRS - Global Open 2022; 10(10S):p 64-65. Doi: 10.1097/01.GOX.0000898644.00762.77 3. DP Baumann, HY Lin, P Chevray. Perforator number predicts fat necrosis in a prospective analysis of breast reconstruction with free TRAM, DIEP, and SIEA flaps. PRS 2010; 125(5):p1335-1341. Doi: 10.1097/PRS.0b013e3181d4fb4a. 4. FJ DellaCroce, HC DellaCroce, CA Blum, SK Sullivan, CG Trahan, MW Wise, IG Brates. Myth-busting the DIEP flap and an introduction to the abdominal perforator exchange (APEX) breast reconstruction technique: A single-surgeon retrospective review. PRS 2019; 143(4):p992-1008. Doi: 10.1097/PRS.0000000000005484