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BACKGROUND: The purpose of this study is to evaluate perfusion related complications in bilateral deep inferior epigastric perforator (DIEP) flap reconstruction of the breast based on perforator selection over a decade. METHODS: A retrospective review of a prospectively maintained DIEP database was performed on all patients undergoing bilateral DIEP reconstruction at a single institution between 2004-2014. The flaps were divided into three cohorts based on perforator location: lateral row only perforator group, medial row only perforator group, and medial plus lateral row perforator group. Postoperative flap related complications were compared and analyzed. RESULTS: Between 2004 and 2014, 818 bilateral DIEP flap reconstructions were performed. Seven hundred and twenty eight flaps met the study criteria. Within the study group, 263 (36.1%) flaps had perforators based only on the lateral row, 225 (30.9%) had perforators based only on the medial row, 240 (33.0%) flaps had perforators based on both the medial and lateral row. The groups were well matched in terms of perforator number and flap weight. Fat necrosis occurrence was significantly higher in flaps based solely on the medial row versus flaps based only on the lateral row perforators (24.5% versus 8.2%, p< 0.001). There was no statistically significant difference in fat necrosis between flaps based only on the lateral row versus flaps based on both the medial and lateral row (8.2% versus 11.6%, p=0.203). Generally, within the same row, increasing the number of perforators decreased the incidence of fat necrosis.
CONCLUSIONS: Perforator selection is critical to minimizing perfusion related flap complications. In bilateral DIEP flaps, lateral row based perforators result in significantly less fat necrosis than medial row based perforators. The addition of a medial row based perforator to a lateral row perforator does not significantly improve postoperative fat necrosis occurrence.