I. See1,3, D. T. Ghorra2,3, L. MacLennan3, N. G. Rabey3, C. M. Malata3,4,5 1University Of Auckland,Auckland, AUCKLAND, New Zealand 2University of Alexandria,Alexandria, ALEXANDRIA, Egypt 3Cambridge University Hospitals NHS Foundation Trust,Department Of Plastic And Reconstructive Surgery,Cambridge, CAMBRIDGE, United Kingdom 4Addenbrooke’s University Hospital,Cambridge Breast Unit,Cambridge, CAMBRIDGE, United Kingdom 5Anglia Ruskin University School of Medicine,Cambridge & Chelmsford, CAMBRIDGE & CHELMSFORD, United Kingdom
Introduction: Double-pedicled lower abdominal free flaps are an effective technique for postmastectomy autologous reconstruction of patients who are slim, nulliparous, large-breasted relative to their abdominal pannus or have midline abdominal scars. These are particularly useful when adjuvant radiotherapy is planned or implant-based reconstruction is declined. Studies suggest they carry no increased morbidity over unipedicled flaps. Both extraflap (independent) and intraflap (dependent) microvascular anastomoses have been employed but utilizing rib-sacrifice technique of internal mammary recipient vessel exposure. We report a consecutive series of 40 patients (80 flaps) undertaken with both configurations without recourse to rib sacrifice. An algorithm incorporating CT angiography of the lower abdominal wall is presented.
Methods: Patients undergoing bipedicled flap unilateral breast reconstruction by a single surgeon (2010-2018) were reviewed with respect to flap type, anastomotic configuration, intercostal space(s) used for the microsurgery and the flap outcomes.
Results: 40 consecutive double-pedicled free flaps (20% of the all breast free flaps) utilizing both intra-flap (n=11) and extra-flap (n=29) techniques with no partial or total flap losses and only one postoperative re-exploration for flap salvage were undertaken in 40 patients with a median age of 46 years (range 27-66). 32 reconstructions were immediate, 3 delayed, and 5 salvage (tertiary). The series comprised 67 deep inferior epigastric artery perforator (DIEP) and 13 superficial inferior epigastric artery (SIEA) flaps. All 80 anastomoses but three (which used the thoracodorsal system) were performed to the internal mammary vessels using the total rib-preserving method. The combinations used were DIEA/DIEA (29), DIEA/SIEA (9) and SIEA-SIEA (2). The median surgery duration was 697 (range 468-790) with a first flap ischemia time of 104 minutes. The 2nd space was used in 22 patients and both 2nd and 3rd in 18 patients. The vein of the 2nd flap was anastomosed anterogradely to the bifurcated IMV vein in 10 cases, retrograde limb in 25, intraflap continuity in 10 and to the thoracodorsal vein in two. The arterial anastomosis of the 2nd pedicle was performed to the retrograde IM artery in 24 cases. Five breasts were liposuctioned for reshaping and three showed minor fat necrosis, which did not require excision.
Conclusion: Bipedicled free abdominal perforator flaps are a reliable option for unilateral breast reconstruction. In view of their technical complexity and prolonged surgical duration, our algorithm facilitates microsurgical flap design in terms of flap pedicle, recipient vessels, and anastomotic permutations to enable successful execution of these operations. CT angiography helps to predict those patients who will benefit from intraflap anastomoses (Moon & Taylor type II vascular anatomy) and thus do not need apriori exposure of the 3rd intercostal space.