Clinical Decision Making Using CTA in Conjoined, Bipedicled DIEP and SIEA for Unilateral Breast Reconstruction

Abstract

Background Using a hemi-abdominal flap for unilateral breast reconstruction in patients may not be ideal due to paucity of abdominal tissue, presence of a lower abdominal midline scar, or a larger and/or ptotic contralateral native breast. Several algorithms exist to make these flaps successful, but all of them require an anastomosis sequence ultimately. In this study, we present our experience with the use of imaging to predict flap dominance and anastomosis sequence to make them consistently successful. Methods Seventy-five consecutive conjoined, bipedicled abdominal composite free flaps for unilateral breast reconstruction were performed. Preoperative computed tomographic angiography (CTA) was obtained to depict the pattern of perforators, flap dominance, and feasibility for intraflap anastomosis. Patient demographics, type/weights of flaps, number of anastomoses, location of perforators, length/type of pedicles, and flap-related complications were reviewed. Results Seventy-five patients underwent composite deep inferior epigastric perforator (DIEP) and/or superficial inferior epigastric artery (SIEA) flaps. There were 62 DIEP-DIEP flaps, 11 DIEP-SIEA flaps, and two SIEA-SIEA flaps. The mean age was 57 years with an average body mass index of 27 kg/m2 and flap weight of 1,054 g. Thirty-one patients underwent intraflap (41%) and 44 patients underwent crania/caudal anastomoses (59%). In comparison to bilateral DIEPs, the total number of perforators was significantly lower (2.9 vs. 3.8), and fat necrosis rate was lower (2.7 vs. 14.4%) as well. Conclusion Guided by preoperative CTA imaging, we recommend the consistent use of these conjoined, bipedicled hemi-abdominal flaps for unilateral breast reconstruction, primarily those with delayed reconstruction and radiation deficits. Preoperative CTA imaging is crucial in directing perforator dissection to maximize overlapping perfusion zones and guide in performing anastomoses.

Dual-pedicled conjoined abdominal flap for breast reconstruction in a patient with previous radiation therapy

“…Delayed breast reconstruction can be difficult because radiotherapy can cause complications in the chest wall [5], resulting in poor cosmetic outcomes after ischemia, wound breakdown, tissue necrosis, fibrosis, and contracture formation [6]. The dual-pedicled DIEP flap is indicated to overcome insufficient skin and soft tissue volume [2]. The dual-pedicled DIEP flap provides an abundant skin paddle and soft tissue volume, so the patient can be satisfied with a natural-looking breast with adequate volume to match the contralateral breast [3].…”

“…For delayed reconstruction of the breast, a dual-pedicled DIEP flap is indicated to overcome insufficient hemi-abdominal tissue and extensive radiation effects on the chest wall [2]. The dual-pedicled DIEP flap provides a sufficient skin envelope and subcutaneous fat tissue for the creation of a natural-looking breast with adequate volume to match the contralateral breast [3].…”

Perforator Mapping Practice for Deep Inferior Epigastric Artery Perforator Flap Reconstructions: A Survey of the Benelux Region

“…The study was designed to minimize this limitation. We did not distinguish between unilateral, bilateral (or stacked 17,18 ) DIEP flap reconstructions in our survey. Some may consider this a limitation.…”

Intraoperative Microvascular Complications in Autologous Breast Reconstruction: The Effects of Resident Training on Microsurgical Outcomes

“…Routine preoperative CTA was obtained on all patients prior to reconstruction. 20 Patients who missed retrospective comorbidity data and intraoperative microsurgical data were excluded from final analysis. All patients had both their oncologic and reconstructive surgeries at our institution.…”