Bilateral autologous breast reconstruction with extended, conjoined deep inferior epigastric perforator (DIEP) flaps
Akhil K. Seth, MD1, Heather A. Erhard, MD2, David T. Greenspun, MD3.
1Beth Israel Deaconess Medical Center, Boston, MA, USA, 2Albert Einstein College of Medicine, Bronx, NY, USA, 3Greenwich Hospital, Greenwich, CT, USA.
The abdomen remains the most popular and reliable donor site for autologous breast reconstruction. However, some patients who require bilateral reconstruction lack sufficient abdominal tissue to be able to create two aesthetically acceptable breast reconstructions using traditional abdominal flaps, such as deep inferior epigastric perforator (DIEP) flaps or transverse rectus abdominus myocutaneous (TRAM) flaps. In particular, single pedicle flaps like these often do not allow for the reliable transfer of adequate volume and/or skin to adequately reestablish the full breadth or "footprint" of the breast. This study summarizes our experience with using "extended, conjoined perforator flaps" to improve the aesthetic results of bilateral breast reconstructions.
Retrospective review of consecutive patients undergoing bilateral breast reconstruction with extended, conjoined perforator flaps over a 3-year period was performed. Extended, conjoined perforator flaps were constructed using two separate arterio-venous pedicles such that each "conjoined flap" was comprised of tissue extending from the midline to the posterior axillary line. In all cases, the tissue supplied by each DIEP flap pedicle (primary pedicle) was harvested in continuity with flank tissue supplied by another vascular pedicle (secondary pedicle). Primary and secondary flap microvascular anastomoses were performed to the anterograde internal mammary (IM) vessels and to a primary pedicle side branch, respectively. Clinical characteristics and outcomes were recorded.
Sixteen patients underwent bilateral autologous breast reconstruction with 32 extended, conjoined DIEP flaps in an immediate (n=20) or delayed (n=12) setting. All patients had preoperative abdominal imaging using magnetic resonance angiography. Average age and body mass index were 49.3 ± 7.0 years and 23.9 ± 2.5, respectively. Three (18.8 %) patients received pre-reconstruction radiation therapy. Mean follow-up was 42.8 months. Secondary flaps were primarily vascularized by a deep circumflex iliac (n=19, 59.3%), superficial inferior epigastric (n=5, 15.6%), or superficial circumflex iliac (n=3, 9.4%) perforator. There were no total flap losses. All patients reported satisfaction with their reconstructive symmetry and final aesthetic result.
Bilateral breast reconstruction with extended, conjoined perforator flaps is safe and reliable in patients with a paucity of central abdominal tissue. The additional skin and soft tissue available with two conjoined flaps allows for greater flexibility in sculpting the shape and providing projection to the reconstructed breast, including restoration of the skin envelope in delayed reconstructions, thus critically optimizing aesthetics. Innovative techniques such as this achieve the superior outcomes expected by today's breast reconstruction patient, emphasizing the sophistication and versatility present within modern reconstructive surgery.
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