P. G. Koolen1, B. T. Lee1, H. Erhard3, D. Greenspun2 1Beth Israel Dearoness Medical Center,Division Of Plastic Surgery,Boston, MA, USA 2Greenwich Hospital,Division Of Plastic Surgery,Greenwich, CT, USA 3Albert Einstein College Of Medicine,Division Of Plastic Surgery,Bronx, NY, USA
Introduction:
Autologous tissue transfer remains a mainstay for reconstruction of the breast. The deep inferior epigastric perforator artery (DIEP) flap has become a primary option at many institutions, yielding satisfactory aesthetic results. This type of reconstruction remains a challenge in thin patients with scant abdominal tissue or in previously irradiated breasts. Previous studies have described the use of stacked DIEP flaps, divided at the midline. We report on a modification with the use of a bipedicled, conjoined DIEP flap in thin patients; this avoids division of preexisting midline vasculature.
Methods:
Patients undergoing a bipedicled, conjoined DIEP flap procedure for unilateral breast reconstruction over the course of two years were included in this study. Pre-operative imaging was obtained using MRA or CTA to support surgical planning of the primary and secondary vascular pedicles. Utilization of the entire abdomen was required for volume and the vascular networks were isolated on both sides. The primary flap was anastomosed to the internal mammary vessels and inset medially, whereas the secondary flap was folded towards the lateral side and a vascular anastomosis was performed from the secondary pedicle to side branches of the primary pedicle (Figure 1). Surgical technique was standardized for consistency.
Results:
We report on our experience with 27 patients undergoing bipedicled, conjoined, stacked DIEP flaps for unilateral (n=25) or bilateral (n=2) breast reconstruction. Important advantages included good volume, projection, ability to sculpt the flap, and creation of a teardrop shaped breast mound. In patients with previous radiation, the additional skin supplied by using both sides of the abdomen allowed for extensive replacement of damaged mastectomy skin. The secondary flap has blood supply across the midline as well as the second vascular pedicle and had “supercharged” perfusion, unlike in stacked flaps where the midline tissue is divided.
Conclusion:
Bipedicled, conjoined DIEP flap procedures are a reliable modification in patients requiring the entire abdominal tissue volume to create a unilateral breast. In using both vascular pedicles and preserving the midline blood supply, this allows for maximal perfusion of both flaps. This modification can be used in thin patients with limited abdominal tissue and does not require contralateral reduction procedures or use of alternative flaps.
