Decision Making in Double-Pedicled DIEP and SIEA Abdominal Free Flap Breast Reconstructions: An Algorithmic Approach and Comprehensive Classification

Abstract

IntroductionThe deep inferior epigastric artery perforator free flap is the gold standard for autologous breast reconstruction. However, using a single vascular pedicle may not yield sufficient tissue in patients with midline scars or insufficient lower abdominal pannus. Double-pedicled free flaps overcome this problem using different vascular arrangements to harvest the entire lower abdominal flap. The literature is, however, sparse regarding technique selection. We therefore reviewed our experience in order to formulate an algorithm and comprehensive classification for this purpose.MethodsAll patients undergoing unilateral double-pedicled abdominal perforator free flap breast reconstruction (AFFBR) by a single surgeon (CMM) over 40 months were reviewed from a prospectively collected database.ResultsOf the 112 consecutive breast free flaps performed, 25 (22%) utilised two vascular pedicles. The mean patient age was 45 years (range = 27–54). All flaps, but one (which used the thoracodorsal system), were anastomosed to the internal mammary vessels using the rib-preservation technique. The surgical duration was 656 min (range = 468–690 min). The median flap weight was 618 g (range = 432–1275 g) and the mastectomy weight was 445 g (range = 220–896 g). All flaps were successful and only three patients requested minor liposuction to reduce and reshape their reconstructed breasts.ConclusionBipedicled free abdominal perforator flaps, employed in a fifth of all our AFFBRs, are a reliable and safe option for unilateral breast reconstruction. They, however, necessitate clear indications to justify the additional technical complexity and surgical duration. Our algorithm and comprehensive classification facilitate technique selection for the anastomotic permutations and successful execution of these operations.Levels of evidenceTherapeutic level IV.

Comparing the thoracodorsal and internal mammary vessels as recipients for microsurgical autologous breast reconstruction: A systematic review and meta‐analysis

“…Previously authors have proposed an algorithm for selecting recipient vessels in free flap breast reconstruction generally (Hamdi, Blondeel, Van Landuyt, & Monstrey, ), in the context of lymph node cancer status (Kronowitz et al, ), when cardiac disease is a consideration (Maher et al, ), and when a bipedicled flap is being used (Malata & Rabey, ; O'Neill et al, ). Based on the results of our review, an algorithm has been created which acknowledges the role of the surgeon's experience in vessel selection and incorporates the surgeon's preference, and considers case specifics (Figure ).…”

Bipedicle-Conjoined Deep Inferior Epigastric Perforator Flaps for Unilateral Breast Reconstruction in Overweight and Obese Patients: Do the Benefits Outweigh the Risks?

“…Adoption of approaches that satisfy these criteria has undoubtedly led to refinements in bipedicle-conjoined DIEP flap reconstruction for unilateral defects and to the use of four-flap solutions for bilateral breast reconstruction. [22][23][24][25][26][27] Published reports suggest that these techniques have thus far been applied predominantly to patients with a normal or low BMI. While many overweight and obese patients possess what many surgeons would consider "adequate" abdominal tissue for standard reconstruction, many of these recon-structions will fall short in restoring one or more of the three essential parameters necessary to achieve an aesthetic reconstruction when only a single pedicle flap is utilized.…”

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

“…8,10 While there are various literature on the types of flap pedicle design and classifications, there is a lack of simple algorithmic approach to select pedicle design and perforators preoperatively. 5,8,11,12 In our institution, we use computed tomographic angiography (CTA) to evaluate and select perforators and pedicle design preoperatively in these patients. In this study, we present our algorithm and experience with using CTA-guided algorithm for conjoined, bipedicled abdominal based breast reconstruction.…”