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The Use of Both Antegrade and Retrograde Internal Mammary Vessels in the Bipedicled (double-barrel) Deep Inferior Epigastric Perforator Flap for Unilateral Breast Reconstruction
Jonatan Hernandez Rosa, MD, Rami D. Sherif, BA, Marco A. Harmaty, MD, Philip J. Torina, MD.
Icahn School of Medicine at Mount Sinai, New York, NY, USA.

Background:
Autologous abdominal tissue transfer is a well-established method of breast reconstruction. The deep inferior epigastric perforator flap (DIEP) has the additional benefit that donor site morbidity is minimal as it spares the muscle and fascia. Reconstruction of the breast with this tissue is limited by the amount of donor tissue available and its blood supply. Conventional DIEP flap reconstruction may not provide adequate volume in cases where the patient is thin, has midline abdominal scars, and/or has a large volume of tissue to replace. One solution to this problem is using a bipedicled DIEP flap, which can incorporate all of the available abdominal tissue.
Bipedicled transverse rectus abdominis myocutaneous (TRAM) flaps and muscle sparing TRAM (MS-TRAM) have been described in the literature addressing similar issues. Both of these methods have the disadvantage of disruption of abdominal wall integrity. Bipedicled DIEP and superficial inferior epigastric artery (SIEA) flaps have also been described in a number of different configurations. The literature appears to favor intra-flap anastomosis, with a minimal exposition of two recipient vessels. It has been demonstrated that both the antegrade internal mammary artery (aIMA) and retrograde internal mammary artery (rIMA) are adequate recipient vessels. The authors are interested in presenting a single center experience with bipedicled DIEP flaps to both the aIMA and rIMA, showing their feasibility and safety.
Methods
A retrospective review was performed identifying patients who underwent unilateral breast reconstruction using a double pedicle DIEP/DIEP or DIEP/SIEA by a single two-surgeon team. Data was collected on patient characteristics, pre-operative risk factors, and post-operative complications. Data was analyzed with a specific emphasis placed on post-operative complications and how they related to pre-operative risk factors.
Results
18 patients were identified who underwent unilateral breast reconstruction using a bipedicled DIEP flap. All patients were female and carried a diagnosis of breast cancer. There were no flap failures, abdominal hernias, or compromises of abdominal wall functionality following the operations.
Conclusions
The results of this study demonstrate that the bipedicled DIEP flap is a feasible and safe alternative when a conventional DIEP flap does not provide adequate volume for breast reconstruction. The second pedicle and vascular inflow allows for ample tissue for successful reconstruction without increased donor site morbidity.


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