The Delay Procedure in Deep Inferior Epigastric Artery Perforator Flap Breast Reconstruction

Abstract

utologous breast reconstruction is the standard of care after mastectomy because of its more natural, permanent results, and high level of patient satisfaction. [1][2][3] The deep inferior epigastric artery perforator (DIEP) flap, using the lower abdominal skin and subcutaneous tissue, is the traditional workhorse for autologous breast reconstruction. 4 Over the years, several techniques have been suggested to address the challenge of insufficient donor tissue for abdominal-based perforator flap breast reconstruction. In addition to the variety of alternative flap options that have been described, stacked or bipedicled abdominal flaps can be used for unilateral breast reconstruction. [5][6][7][8][9][10][11][12][13][14][15][16] For bilateral breast reconstruction, bilateral stacked flaps or four-flap breast reconstructions (eg, a combination of abdominal flaps and other free flaps) can be considered, using two separate donor sites. 17-21 For these cases, the stacked hemiabdominal extended perforator (SHAEP) flap was previously introduced using a single abdominal donor site to limit morbidity. 6 However, these types of Background: The delay procedure in deep inferior epigastric artery perforator (DIEP) flap breast reconstruction, in which the reduced-caliber choke vessels play a major role, can provide more well-perfused tissue than a standard DIEP flap. The aim of this study was to review the authors' experience with this technique, evaluate the indications, and analyze the surgical outcomes. Methods: A retrospective study was conducted of all consecutive DIEP delay procedures performed between March of 2019 and June of 2021. Patient demographic characteristics, operative details, and complications were registered. Patients had preoperative imaging by magnetic resonance angiography to select dominant perforators. The surgical technique involves a two-stage operation. During the first operation, the flaps were pedicled on a dominant perforator and a lateral skin bridge extending toward the lateral flank and lumbar fat; in a second stage, the flap was harvested and transferred. Results: A total of 82 extended DIEP delay procedures were performed to reconstruct 154 breasts. The majority were bilateral breast reconstructions (87.8%). The delay procedure was used for 38 primary reconstructions (46.3%) and 32 tertiary reconstructions (39.0%). The primary indication was the need for additional volume (79.3%), followed by extensive abdominal scarring and liposuction. After the first operation, seroma was the most frequently observed complication (7.3%). After the second operation, three total flap losses (1.9%) were observed. Conclusions: The delay procedure in DIEP flap breast reconstruction results in the harvest of a good amount of abdominal tissue by adding a preliminary procedure. This technique can convert cases previously considered unsuitable into suitable candidates for abdominal-based breast reconstruction. (Plast.