CLINICAL ARTICLE
A Strategic Approach for DIEP Flap Breast Reconstruction in Patients With a Vertical Midline Abdominal Scar Chang-Cheng Chang, MD,*þ Jung-Ju Huang, MD,Þþ Chih-Wei Wu, MD,Þþ Randall O. Craft, MD,§ Anita A. May-Ling Liem, MD,Þ Jen-Hsiang Shen, MD,* and Ming-Huei Cheng, MD, MBA, FACSÞþ Background: Deep inferior epigastric perforator (DIEP) f laps have become broadly accepted for autologous breast reconstruction. Our aim was to analyze outcomes and describe technical strategies to improve survival when harvesting the entire DIEP f lap with a midline scar. Methods: We retrospectively reviewed charts from March of 2000 to November of 2007; 186 DIEP flaps in 183 patients were used for breast reconstruction, including 18 f laps (9.68%) in 17 patients with previous lower midline abdomen scars. The patients were classified into 3 groups. Group 1: hemi-DIEP f laps (n = 5);. group 2: DIEP f laps that included tissue crossing the midline (n = 10); and group 3: entire-DIEP f laps (with zone IV) (n = 3). Results: Reexploration for venous congestion and partial f lap loss were encountered in 1 patient in group 1. Average f lap-used ratio was 68.75 T 8.95% in group 2. Three f laps developed partial loss and underwent subsequent debridement. In group 3, entire DIEP f laps were designed with higher, bilateral superficial inferior epigastric venous drainages and intraflap pedicle-to-pedicle anastomosis. The first 2 cases underwent partial flap loss and debridement. The third case of bipedicle anastomosis achieved complete f lap survival. Conclusions: The hemi-DIEP f lap is a safer method for the patient with a lower abdominal midline scar but limits the reconstructive volume. Carefully evaluating the perfusion across midline scar intraoperatively is crucial for deciding how much contralateral tissue should be discarded. Double pedicles anastomosis is an assurance for using entire DIEP f lap with lower midline scar. Key Words: deep inferior epigastric perforator flap, breast reconstruction, lower midline abdominal scar (Ann Plast Surg 2014;73: S6YS11)
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eep inferior epigastric perforator (DIEP) f laps have become broadly accepted for autologous breast reconstruction in an effort to reduce the donor-site morbidity traditionally associated with abdominal-based f laps.1Y3 The presence of a vertical midline abdominal scar has been considered problematic because of decreased perfusion across the midline of the abdominal skin paddle. Sano et al described a lack of long-term reperfusion across a vertical midline scar in an animal model4; subsequent clinical series have looked at the outcomes of preexisting abdominal scars at any location, but little
Received March 26, 2014, and accepted for publication, after revision, April 1, 2014. From the *Division of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chia Yi; †Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital; ‡College of Medicine, Chang Gung University, Taoyuan, Taiwan, Republic of China; and §Plastic and Reconstructive Surgery, Banner MD Anderson Cancer Center, Gilbert, AZ. Sources of funding and conflicts of interest: none declared. This paper was presented at the 3rd World Association of Plastic Surgeons of Chinese Decent, Xian, China, October 11 to 13, 2012. Reprints: Ming-Huei Cheng, MD, MBA, FACS, Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University., 5 Fu-Hsing Street, Kueishan, Taoyuan 333, Taiwan, Republic of China. E-mail: [email protected]. Copyright * 2014 by Lippincott Williams & Wilkins ISSN: 0148-7043/14/7301-S006 DOI: 10.1097/SAP.0000000000000244
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data are available for the clinical feasibility of augmenting hemi abdominal f laps by including tissue across an existing vertical scar.5,6 Because tissue perfusion across the midline scar may be compromised, hemi-DIEP or hemi-TRAM f laps are the preferred choice for the patient with a previous midline abdominal scar. Unfortunately, the use of a hemi f lap can limit the volume of tissue available and the subsequent aesthetic outcome in some patients. Dragu et al described their series of using MS-2-vertical rectus abdominis myocutaneous (VRAM) free f laps as an alternative in the face of vertical midline scars with low complications.7 Henry et al described their series of 11 patients who had tissue included beyond a midline scar for DIEP f lap reconstruction, noting a higher complication rate in the scarred versus unscarred abdomen (55% vs 25%; P = 0.04).8 We presented our clinical series of DIEP f lap reconstructions that include territories across an existing midline scar, quantifying the volume of tissue included and the attendant complications. We also presented 2 cases to illustrate technical approaches for increasing survival of the entire abdominal f lap, including the contralateral lateral zone9 (zone IV).
PATIENTS AND METHODS A retrospective chart review was performed on all patients undergoing DIEP f lap breast or chest wall reconstruction between March 2000 and November 2007 at Chang Gung Memorial Hospital. One hundred eighty-six DIEP f laps in 183 patients were performed, including 18 f laps in 17 patients with a vertical midline scar that extended at least from the umbilicus to the pubis. All of the operations were performed by the senior author. All patients were followed up for at least 1 year. The medical charts of all patients were reviewed for information on patients’ age, scar etiology, comorbidities, reconstructive procedures, volume of f lap utilized, and complications. One scar resulted from a lower anterior resection for rectal cancer. All f lap volumes were determined by water displacement intraoperatively. For comparison, the flaps were classified into 3 groups. Group 1: patients who underwent hemi-DIEP flap reconstruction without inclusion of tissue beyond the midline (n = 5), group 2: DIEP flaps that included tissue crossing the midline (n = 10), and Group 3: the entire DIEP flap encompassing the contralateral lateral zone (zone IV) used (n = 3). One patient underwent differentially split DIEP flap; one flap was in group 1, and the other was in group 2.
RESULTS The average age was 51.33 T 8.45 years, ranging from 31 to 68 years old. The main etiologies of previous lower midline scar (16/17 [94.12%]) were gynecologic procedures, including hysterectomy, oophorectomy, and cesarean section for delivery. One patient with previous radiotherapy developed partial f lap loss and subsequent debridement in group 1 (Table 1). Average f lap-used ratio of 68.75 T 8.95% was used in group 2 with 19% volume greater than group 1. Three f laps (30%) developed partial necrosis, and 1 f lap with fat necrosis (10%) in group 2 (Table 2). Two of 3 cases in group 3 developed complication. One DIEP f lap was designed higher to Annals of Plastic Surgery
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Strategy for DIEP Flap with Midline Scar
TABLE 1. Demographics of the 5 Hemi-DIEP Flaps Used for Unilateral Breast Reconstruction in 5 Patients Patient No.
Age (yr)
Scar Etiology
1 2
45 68
C/S C/S
3 4 5a#
60 49 50
C/S C/S C/S
Comorbidity Factors
Flap Size (cm cm)
Flap Weight Harvested (g)
Flap Weight Used (g)
Acute Complications
Flap Outcome
No Previous radiotherapy, liver cirrhosis Previous radiotherapy No No
34 13 38 12
925 760
480 420
No Venous congestion
Complete survival Partial flap loss
34 12 36 12 44 14
840 500 695
350 270 235
No No No
Complete survival Complete survival Complete survival
a#
Differentially split DIEP f laps in 1 patient. C/S, cesarean section.
minimize the scar effects in a patient whose midline scar was relatively low but still developed partial f lap necrosis later. The second case had compromised f lap circulation across the midline with zone IV venous congestion. The patient subsequently underwent the salvage procedures of f lap reinset and bilateral superficial epigastric venous drainages. However, partial f lap loss still developed, and secondary stage revision was needed. The third f lap underwent intraf lap pedicle-to-pedicle anastomosis for both arterial and venous augmentation, achieving complete f lap survival without any complications (Table 3).
Case Presentations Case 1 A 60-year-old nonsmoking woman with a previous low vertical midline abdominal scar underwent extended DIEP f lap reconstruction for right breast and chest wall reconstruction because of severe burn scar contracture (Figs. 1A, B). The contralateral breast augmentation was performed through our previously described
midline approach.10 The anticipated perforator was detected by portable hand-held Doppler and marked. Because of the extent of defect of the postexcision of hypertrophic scar, the entire DIEP f lap including the contralateral lateral zone (zone IV) was required for the reconstruction of the chest and breast. The f lap measured 30 12 cm, weight of 600 gm, with one perforator approximately 1.0 mm in diameter (Figs. 2A, B). Bilateral superficial epigastric veins were preserved up to 7 cm in length. The ipsilateral superficial inferior epigastric vein (SIEV-i) was anastomosed to the internal mammary vein rather than the deep inferior epigastric vein intraoperatively. However, venous congestion developed intraoperatively on the contralateral lateral side postarterial and venous anastomoses. The contralateral superficial inferior epigastric vein (SIEV-c) was anastomosed to SIEV-i in end-to-side fashion (Fig. 3). Within 12 hours postoperatively, bluish areas appeared and extended over part of the contralateral medial and contralateral lateral territories. The patient was taken back to the operating room for reexploration. Both arterial and venous anastomoses were patent, and the f lap was reinset with a tension-free wound closure. However, partial f lap loss still
TABLE 2. Demographics of the 10 DIEP Flaps Including the Tissues Across the Midline Scar Age (yr)
Scar Etiology
Comorbidity Factor
Flap size Harvested (cm cm)
Flap Weight Used (gm)
Flap Used Ratio (%)
Acute Complications
1 2
31 54
C/S LAR
No No
40 14 38 12
690 570
74.19 64.80
No No
3
46
C/S
38 13
600
72.29
No
4
60
C/S
38 12
370
62.70
5
44
C/S
No
32 12
375
88.24
6
56
C/S
No
34 12
525
66.88
7
52
C/S
No
36 12
715
74.50
8
44
C/S
No
38 12
500
66.67
9
49
Oophorectomy
No
34 12
460
58.23
No
10b#
50
C/S
No
44 14
410
58.99
No
Patient No.
Previous radiotherapy No
Average/ 48.60 T 8.07 Percentage
521.50 T 122.68 68.75 T 8.95
Venous congestion No No Venous congestion No
2/10=20.00%
Other Procedures
Flap Outcome
Complete survival Partial loss SIEV-i to IMV Complete survival Complete survival Partial loss Flap reinset Partial loss Contralateral Complete mastopexy survival Complete survival Complete survival 3/10 = 30%
b#
Differentially split DIEP f laps in 1 patient. C/S, cesarean section; IMV, internal mammary vein; LAR, lower anterior resection.
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TABLE 3. Demographics of the 3 Entire DIEP Flaps With Midline Scar Were Used for Unilateral Breast Reconstruction Age (yr)
Scar Etiology
Co-Morbidity Factors
Flap size (cm cm) Harvested and Weight Used (g)
Reconstruction Approach
Immediate Complications
Flap Outcome
1
59
Hysterectomy
No
30 12, 580
Bilateral SIEVs drainage
Partial loss
2
47
C/S
38 12, 710
Design higher
3
60
C/S
DM, Previous radiotherapy No
34 12, 675
Intraflap pedicle to pedicle anastomosis, contralateral breast reduction
Contralateral lateral zone arterial circulation compromised, venous congestion Contralateral lateral zone arterial circulation compromised No
Patient No.
Partial loss Complete survival
C/S, cesarean section.
FIGURE 1. A and B, A 60-year-old woman requested breast reconstruction because of a burn injury experienced in childhood. Scar contracture of right chest vail, breast hypoplasia, and nipple displacement were found. A, Anteroposterior view. B, Lateral view.
FIGURE 2. A, Preoperative markings were drawn for planned incision. The hemi-DIEP f lap would not be adequate for coverage, so the entire DIEP f lap was designed and harvested. B, The deep inferior epigastric perforator f lap was harvested.
FIGURE 3. Venous congestion developed intraoperatively in the contralateral lateral zone after anastomoses. Therefore, the contralateral SIEV (SIEV-c) was anastomosed to the ipsilateral SIEV (SIEV-i) with end-to-side fashion as a salvage procedure. S8
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Strategy for DIEP Flap with Midline Scar
FIGURE 4. Within the 12 hours postoperatively, some bluish area appeared and extended over parts of zone III and zone IV areas. Insufficient flap circulation was also found. The flap was reinset with a tension-free closure to promote flap circulation. Partial flap necrosis occurred 1 week postoperatively.
developed because of insufficient arterial perfusion crossing the midline scar to supply the contralateral lateral zone (Fig. 4). The partial f lap necrosis was debrided, and the residual f lap was reinset 7 days postoperatively. One revision of the f lap was performed 8 months postoperatively. The bilateral breasts contour 1 year postoperatively was ultimately acceptable (Figs. 5A, B).
Case 2 A 60-year-old nonsmoking woman with a lower midline abdominal scar presented for delayed right breast reconstruction status post radical mastectomy and radiotherapy 4 years prior. The DIEP f lap outline was marked, and the possible locations of perforators were detected by handheld Doppler probe. After the scar excision and contracture release, a large defect was created, and the entire DIEP f lap was needed for coverage (Fig. 6). Bilateral SIEVs were preserved and dissected. To augment the arterial perfusion and venous drainage across the midline scar, perforators of each side along with the deep inferior epigastric vessels were meticulously dissected and preserved. The left side inferior epigastric vessels, which was intended to be anastomosed to the internal mammary vessels, were dissected out both cephalically and caudally to gain the sufficient pedicle length. Then, the entire DIEP f lap, 34 12 cm, weighing 675 g, based on bilateral pedicles was disconnected from the abdomen. The extended distal ends of the left inferior epigastric vessels were anastomosed to the proximal ends of the right inferior epigastric vessels across the midline scar as an intraf lap pedicle-to-pedicle augmentation (Fig. 7A). After the successful intraflap microvascular
FIGURE 6. A 60-year-old nonsmoking woman with a lower midline abdominal scar because of previous gynecological procedure, underwent the delayed right breast reconstruction. Postmastectomy and radiotherapy for 4 years.
anastomosis, the f lap was transferred to the right chest for conventional end-to-end anastomosis between the proximal end of the left deep inferior epigastric vessels and internal mammary vessels. The f lap circulation was confirmed intraoperatively before f lap inset. The left-side reduction mammoplasty was performed for improved symmetry simultaneously. The postoperative f lap circulation was adequate across the midline including the contralateral lateral zone, with complete f lap survival achieved (Fig. 7B).
DISCUSSION Gill et al retrospectively reviewed 758 DIEP f lap cases for breast reconstruction over 10 years, concluding that previous abdominal scars were not a significant risk factor for f lap complications.11 Parrett et al had similar conclusions in their series of 104 f laps performed in the presence of previous abdominal scars.6 However, both series included all abdominal scar types, regardless of orientation or position. The specific outcomes of midline vertical scars of DIEP f lap or the complications associated with capturing territories beyond the midline scar were not addressed. The presence of vertical midline scars presents a technical challenge in flap harvest. Although the use of a hemi flap is the most conservative approach, the limited volume is not always ideal for the clinical scenario.
FIGURE 5. A and B, At a 1-year follow-up, the patient was satisfied with the symmetric and pleasing breast mounds with a secondary revised reconstruction. A, Anteroposterior view. B, Lateral view. * 2014 Lippincott Williams & Wilkins
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FIGURE 7. A and B, The extended distal stump of left deep inferior epigastric vessels were anastomosed to the proximal stump of right deep inferior epigastric vessels (contralateral side) across the midline scar as an intraf lap pedicle to pedicle arterial and venous augmentation. Complete f lap survival was achieved postoperatively.
Numerous surgical techniques have been reported for promoting TRAM f lap circulation across midline scars, including bipedicled f laps,12 retrograde, and contralateral supercharging.13Y15 Most of the procedures were complicated, and the definite effect remained controversial because of the limited cases. Heller et al15 reviewed 43 cases of patients with lower abdominal midline scars for TRAM f laps reconstruction. Various reconstructive approaches were described in his series, including free TRAM f laps incorporating tissue across the midline scar, free TRAM f laps designed higher, pedicled hemi-TRAM f lap plus contralateral free hemi-TRAM f lap, and bipedicled TRAM f laps. The majority of cases (26/43) used only hemif lap. Surprisingly, he found that tissue across midline scars could have good perfusion in some cases, making the territories suitable for reconstruction.15 It is hypothesized that angiogenesis occurs across the scars, allowing the territories across the midline scars to survive as a random f lap. Other authors reported that angiogenesis involving scar tissues can increase the microvascular density in the healing tissue.16 Han et al used more superiorly-located f laps in a rats model, finding that a midline abdominal scar could provide benefits similar to a delay with increasing size and density of the subdermal plexus.17 Conversely, Sano et al reported that contralateral hemif laps across the midline scar were all nonviable in a rat model.4 Midline abdominal scars were thus considered a relative contraindication for abdominal-based autologous reconstruction.2
In our series, we observed an average f lap use ratio of 68.75 T 8.95%, approaching two thirds of the entire abdominal f lap could be used, but with 30% complication in the contralateral lateral zone eventually developed partial f lap loss. The distance of the dominant perforator from the midline, not the number of perforators, is proposed as the determinant factor of the f lap reliability.2,18,19 Therefore, if the territory well perfused by the perforator does not provide adequate volume, bipedicles, additional supercharging or intraf lap pedicle to pedicle microvascular anastomoses are strongly recommended.20 In the clinical scenario where the entire DIEP f lap with an incorporated midline scar was harvested to reconstruct a large defect, venous congestion in the contralateral lateral zone is the key for developing partial f lap loss and fat necrosis. Cheng et al has described that the contralateral lateral zone in DIEP f laps were highly reliable even when a single perforator was incorporated.18 However, although bilateral pedicles can be intraf lap connected for augmented arterial perfusion and venous drainage, venous congestion in the contralateral lateral zone is still encountered where the superficial inferior epigastric vein (SIEV) is the dominant drainage. As we described in our first clinical case, salvage is attempted with anastomosis of the contralateral SIEV to the ipsilateral superficial system. Alternatively, another recipient venous drainage system can be used.21,22
FIGURE 8. The strategies for DIEP f lap breast reconstruction in patients with midline abdominal scars. A, indicates artery; DIEA-c, contralateral deep inferior epigastric artery; DIEA-i, ipsilateral deep inferior epigastric artery; DIEV-1, deep inferior epigastric vein 1; SIEV-i, ipsilateral superficial inferior epigastric vein; V, vein. S10
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In concordance with previous series, we found that tissue incorporated across the midline scar were viable in select cases. Although angiogenesis may extend across the scar tissue, the reliable distance remains unknown. The average f lap-used ratio in the group using the tissues across the midline scar was 68.75 T 8.95%. Although the contralateral lateral zone and possibly a part of contralateral medial zone were discarded in group 2, the complication rate was higher than group 1, which did not incorporate tissue across the midline. In our opinion, 2 cm across the midline could be reliable for f lap transfer. The strategies for DIEP f laps breast reconstruction in patients with lower midline scars are summarized in Figure 8. When lower midline abdominal scars are present, the hemi-DIEP f lap is the safest way but not absolutely needed. In select cases, the contralateral lateral zone and parts of the contralateral medial zone can be discarded, maintaining tissue across the midline with careful intraoperative f lap evaluation. In cases where the contralateral lateral zone is needed, intraf lap arterial and venous augmentation by connecting bilateral pedicles is strongly suggested. We can connect contralateral DIEA to ipsilateral DIEA, either with end-to-side fashion or end-to-ipsilateral DIEA distal end for the arterial insufficiency. If venous congestion is encountered, the contralateral SIEV can be anastomosed to the ipsilateral SIEV or DIEV as a salvage procedure.
CONCLUSIONS The hemi-DIEP f lap is a safer method for the patient with a lower abdominal midline scar, but it limits the available reconstructive volume. Carefully evaluating the tissue perfusion intraoperatively is crucial for deciding how much contralateral tissue should be discarded; 2 cm across the midline appears to be reliable in our experience. Intraf lap pedicle anastomoses is an assurance for using the entire DIEP f lap with an incorporated lower midline scar for large defect reconstruction. REFERENCES 1. Allen RJ, Treece P. Deep inferior epigastric perforator flap for breast reconstruction. Ann Plast Surg. 1994;32:32Y38. 2. Blondeel PN. One hundred free DIEP flap breast reconstructions: a personal experience. Br J Plast Surg. 1999;52:104Y111. 3. Garvey PB, Buchel EW, Pockaj BA, et al. DIEP and pedicled TRAM flaps: a comparison of outcomes. Plast Reconstr Surg. 2006;117:1711Y1719; discussion 1720Y1711. 4. Sano K, Hallock GG, Rice DC. A vertical midline scar is a ’high-risk’ factor for maximum survival of the rat TRAM flap. Ann Plast Surg. 2003;51:403Y408.
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Strategy for DIEP Flap with Midline Scar
5. Hsieh F, Kumiponjera D, Malata CM. An algorithmic approach to abdominal flap breast reconstruction in patients with pre-existing scarsYresults from a single surgeon’s experience. J Plast Reconstr Aesthet Surg. 2009;62:1650Y1660. 6. Parrett BM, Caterson SA, Tobias AM, et al. DIEP flaps in women with abdominal scars: are complication rates affected? Plast Reconstr Surg. 2008;121:1527Y1531. 7. Dragu A, Unglaub F, Wolf MB, et al. Scars and perforator-based flaps in the abdominal region: a contraindication? Can J Surg. 2010;53:137Y142. 8. Henry SL, Chang CC, Misra A, et al. Inclusion of tissue beyond a midline scar in the deep inferior epigastric perforator flap. Ann Plast Surg. 2011;67: 251Y254. 9. Henry SL, Cheng MH. A call for clarity in TRAM/DIEP zones. Plast Reconstr Surg. 2010;125:210eY211e. 10. Huang JJ, Chao LF, Wu CW, et al. Simultaneous scarless contralateral breast augmentation during unilateral breast reconstruction using bilateral differentially split DIEP flaps. Plast Reconstr Surg. 2011;128:593eY604e. 11. Gill PS, Hunt JP, Guerra AB, et al. A 10-year retrospective review of 758 DIEP flaps for breast reconstruction. Plast Reconstr Surg. 2004;113:1153Y1160. 12. Wagner DS, Michelow BJ, Hartrampf CR Jr. Double-pedicle TRAM flap for unilateral breast reconstruction. Plast Reconstr Surg. 1991;88:987Y997. 13. Pennington DG, Nettle WJ, Lam P. Microvascular augmentation of the blood supply of the contralateral side of the free transverse rectus abdominis musculocutaneous flap. Ann Plast Surg. 1993;31:123Y126; discussion 126Y127. 14. Semple JL. Retrograde microvascular augmentation (turbocharging) of a single-pedicle TRAM flap through a deep inferior epigastric arterial and venous loop. Plast Reconstr Surg. 1994;93:109Y117. 15. Heller L, Feledy JA, Chang DW. Strategies and options for free TRAM flap breast reconstruction in patients with midline abdominal scars. Plast Reconstr Surg. 2005;116:753Y759; discussion 760Y751. 16. Brown NJ, Smyth EA, Cross SS, et al. Angiogenesis induction and regression in human surgical wounds. Wound Repair Regen. 2002;10:245Y251. 17. Han S, Sup Eom J, Ho Kim D. Effects of the abdominal midline incision on the survival of the transverse rectus abdominis musculocutaneous flap in rat model. Ann Plast Surg. 2003;50:171Y176. 18. Cheng MH, Robles JA, Ulusal BG, et al. Reliability of zone IV in the deep inferior epigastric perforator flap: a single center’s experience with 74 cases. Breast. 2006;15:158Y166. 19. Heitmann C, Felmerer G, Durmus C, et al. Anatomical features of perforator blood vessels in the deep inferior epigastric perforator flap. Br J Plast Surg. 2000;53:205Y208. 20. Schoeller T, Wechselberger G, Roger J, et al. Management of infraumbilical vertical scars in DIEP-flaps by crossover anastomosis. J Plast Reconstr Aesthet Surg. 2007;60:524Y528. 21. Villafane O, Gahankari D, Webster M. Superficial inferior epigastric vein (SIEV): ‘lifeboat’ for DIEP/TRAM flaps. Br J Plast Surg. 1999;52:599. 22. Ali R, Bernier C, Lin YT, et al. Surgical strategies to salvage the venous compromised deep inferior epigastric perforator flap. Ann Plast Surg. 2010;65:398Y406.
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A Strategic Approach for DIEP Flap Breast Reconstruction in Patients With a Vertical Midline Abdominal Scar Chang-Cheng Chang, MD,*þ Jung-Ju Huang, MD,Þþ Chih-Wei Wu, MD,Þþ Randall O. Craft, MD,§ Anita A. May-Ling Liem, MD,Þ Jen-Hsiang Shen, MD,* and Ming-Huei Cheng, MD, MBA, FACSÞþ Background: Deep inferior epigastric perforator (DIEP) f laps have become broadly accepted for autologous breast reconstruction. Our aim was to analyze outcomes and describe technical strategies to improve survival when harvesting the entire DIEP f lap with a midline scar. Methods: We retrospectively reviewed charts from March of 2000 to November of 2007; 186 DIEP flaps in 183 patients were used for breast reconstruction, including 18 f laps (9.68%) in 17 patients with previous lower midline abdomen scars. The patients were classified into 3 groups. Group 1: hemi-DIEP f laps (n = 5);. group 2: DIEP f laps that included tissue crossing the midline (n = 10); and group 3: entire-DIEP f laps (with zone IV) (n = 3). Results: Reexploration for venous congestion and partial f lap loss were encountered in 1 patient in group 1. Average f lap-used ratio was 68.75 T 8.95% in group 2. Three f laps developed partial loss and underwent subsequent debridement. In group 3, entire DIEP f laps were designed with higher, bilateral superficial inferior epigastric venous drainages and intraflap pedicle-to-pedicle anastomosis. The first 2 cases underwent partial flap loss and debridement. The third case of bipedicle anastomosis achieved complete f lap survival. Conclusions: The hemi-DIEP f lap is a safer method for the patient with a lower abdominal midline scar but limits the reconstructive volume. Carefully evaluating the perfusion across midline scar intraoperatively is crucial for deciding how much contralateral tissue should be discarded. Double pedicles anastomosis is an assurance for using entire DIEP f lap with lower midline scar. Key Words: deep inferior epigastric perforator flap, breast reconstruction, lower midline abdominal scar (Ann Plast Surg 2014;73: S6YS11)
D
eep inferior epigastric perforator (DIEP) f laps have become broadly accepted for autologous breast reconstruction in an effort to reduce the donor-site morbidity traditionally associated with abdominal-based f laps.1Y3 The presence of a vertical midline abdominal scar has been considered problematic because of decreased perfusion across the midline of the abdominal skin paddle. Sano et al described a lack of long-term reperfusion across a vertical midline scar in an animal model4; subsequent clinical series have looked at the outcomes of preexisting abdominal scars at any location, but little
Received March 26, 2014, and accepted for publication, after revision, April 1, 2014. From the *Division of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chia Yi; †Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital; ‡College of Medicine, Chang Gung University, Taoyuan, Taiwan, Republic of China; and §Plastic and Reconstructive Surgery, Banner MD Anderson Cancer Center, Gilbert, AZ. Sources of funding and conflicts of interest: none declared. This paper was presented at the 3rd World Association of Plastic Surgeons of Chinese Decent, Xian, China, October 11 to 13, 2012. Reprints: Ming-Huei Cheng, MD, MBA, FACS, Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University., 5 Fu-Hsing Street, Kueishan, Taoyuan 333, Taiwan, Republic of China. E-mail: [email protected]. Copyright * 2014 by Lippincott Williams & Wilkins ISSN: 0148-7043/14/7301-S006 DOI: 10.1097/SAP.0000000000000244
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data are available for the clinical feasibility of augmenting hemi abdominal f laps by including tissue across an existing vertical scar.5,6 Because tissue perfusion across the midline scar may be compromised, hemi-DIEP or hemi-TRAM f laps are the preferred choice for the patient with a previous midline abdominal scar. Unfortunately, the use of a hemi f lap can limit the volume of tissue available and the subsequent aesthetic outcome in some patients. Dragu et al described their series of using MS-2-vertical rectus abdominis myocutaneous (VRAM) free f laps as an alternative in the face of vertical midline scars with low complications.7 Henry et al described their series of 11 patients who had tissue included beyond a midline scar for DIEP f lap reconstruction, noting a higher complication rate in the scarred versus unscarred abdomen (55% vs 25%; P = 0.04).8 We presented our clinical series of DIEP f lap reconstructions that include territories across an existing midline scar, quantifying the volume of tissue included and the attendant complications. We also presented 2 cases to illustrate technical approaches for increasing survival of the entire abdominal f lap, including the contralateral lateral zone9 (zone IV).
PATIENTS AND METHODS A retrospective chart review was performed on all patients undergoing DIEP f lap breast or chest wall reconstruction between March 2000 and November 2007 at Chang Gung Memorial Hospital. One hundred eighty-six DIEP f laps in 183 patients were performed, including 18 f laps in 17 patients with a vertical midline scar that extended at least from the umbilicus to the pubis. All of the operations were performed by the senior author. All patients were followed up for at least 1 year. The medical charts of all patients were reviewed for information on patients’ age, scar etiology, comorbidities, reconstructive procedures, volume of f lap utilized, and complications. One scar resulted from a lower anterior resection for rectal cancer. All f lap volumes were determined by water displacement intraoperatively. For comparison, the flaps were classified into 3 groups. Group 1: patients who underwent hemi-DIEP flap reconstruction without inclusion of tissue beyond the midline (n = 5), group 2: DIEP flaps that included tissue crossing the midline (n = 10), and Group 3: the entire DIEP flap encompassing the contralateral lateral zone (zone IV) used (n = 3). One patient underwent differentially split DIEP flap; one flap was in group 1, and the other was in group 2.
RESULTS The average age was 51.33 T 8.45 years, ranging from 31 to 68 years old. The main etiologies of previous lower midline scar (16/17 [94.12%]) were gynecologic procedures, including hysterectomy, oophorectomy, and cesarean section for delivery. One patient with previous radiotherapy developed partial f lap loss and subsequent debridement in group 1 (Table 1). Average f lap-used ratio of 68.75 T 8.95% was used in group 2 with 19% volume greater than group 1. Three f laps (30%) developed partial necrosis, and 1 f lap with fat necrosis (10%) in group 2 (Table 2). Two of 3 cases in group 3 developed complication. One DIEP f lap was designed higher to Annals of Plastic Surgery
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Strategy for DIEP Flap with Midline Scar
TABLE 1. Demographics of the 5 Hemi-DIEP Flaps Used for Unilateral Breast Reconstruction in 5 Patients Patient No.
Age (yr)
Scar Etiology
1 2
45 68
C/S C/S
3 4 5a#
60 49 50
C/S C/S C/S
Comorbidity Factors
Flap Size (cm cm)
Flap Weight Harvested (g)
Flap Weight Used (g)
Acute Complications
Flap Outcome
No Previous radiotherapy, liver cirrhosis Previous radiotherapy No No
34 13 38 12
925 760
480 420
No Venous congestion
Complete survival Partial flap loss
34 12 36 12 44 14
840 500 695
350 270 235
No No No
Complete survival Complete survival Complete survival
a#
Differentially split DIEP f laps in 1 patient. C/S, cesarean section.
minimize the scar effects in a patient whose midline scar was relatively low but still developed partial f lap necrosis later. The second case had compromised f lap circulation across the midline with zone IV venous congestion. The patient subsequently underwent the salvage procedures of f lap reinset and bilateral superficial epigastric venous drainages. However, partial f lap loss still developed, and secondary stage revision was needed. The third f lap underwent intraf lap pedicle-to-pedicle anastomosis for both arterial and venous augmentation, achieving complete f lap survival without any complications (Table 3).
Case Presentations Case 1 A 60-year-old nonsmoking woman with a previous low vertical midline abdominal scar underwent extended DIEP f lap reconstruction for right breast and chest wall reconstruction because of severe burn scar contracture (Figs. 1A, B). The contralateral breast augmentation was performed through our previously described
midline approach.10 The anticipated perforator was detected by portable hand-held Doppler and marked. Because of the extent of defect of the postexcision of hypertrophic scar, the entire DIEP f lap including the contralateral lateral zone (zone IV) was required for the reconstruction of the chest and breast. The f lap measured 30 12 cm, weight of 600 gm, with one perforator approximately 1.0 mm in diameter (Figs. 2A, B). Bilateral superficial epigastric veins were preserved up to 7 cm in length. The ipsilateral superficial inferior epigastric vein (SIEV-i) was anastomosed to the internal mammary vein rather than the deep inferior epigastric vein intraoperatively. However, venous congestion developed intraoperatively on the contralateral lateral side postarterial and venous anastomoses. The contralateral superficial inferior epigastric vein (SIEV-c) was anastomosed to SIEV-i in end-to-side fashion (Fig. 3). Within 12 hours postoperatively, bluish areas appeared and extended over part of the contralateral medial and contralateral lateral territories. The patient was taken back to the operating room for reexploration. Both arterial and venous anastomoses were patent, and the f lap was reinset with a tension-free wound closure. However, partial f lap loss still
TABLE 2. Demographics of the 10 DIEP Flaps Including the Tissues Across the Midline Scar Age (yr)
Scar Etiology
Comorbidity Factor
Flap size Harvested (cm cm)
Flap Weight Used (gm)
Flap Used Ratio (%)
Acute Complications
1 2
31 54
C/S LAR
No No
40 14 38 12
690 570
74.19 64.80
No No
3
46
C/S
38 13
600
72.29
No
4
60
C/S
38 12
370
62.70
5
44
C/S
No
32 12
375
88.24
6
56
C/S
No
34 12
525
66.88
7
52
C/S
No
36 12
715
74.50
8
44
C/S
No
38 12
500
66.67
9
49
Oophorectomy
No
34 12
460
58.23
No
10b#
50
C/S
No
44 14
410
58.99
No
Patient No.
Previous radiotherapy No
Average/ 48.60 T 8.07 Percentage
521.50 T 122.68 68.75 T 8.95
Venous congestion No No Venous congestion No
2/10=20.00%
Other Procedures
Flap Outcome
Complete survival Partial loss SIEV-i to IMV Complete survival Complete survival Partial loss Flap reinset Partial loss Contralateral Complete mastopexy survival Complete survival Complete survival 3/10 = 30%
b#
Differentially split DIEP f laps in 1 patient. C/S, cesarean section; IMV, internal mammary vein; LAR, lower anterior resection.
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TABLE 3. Demographics of the 3 Entire DIEP Flaps With Midline Scar Were Used for Unilateral Breast Reconstruction Age (yr)
Scar Etiology
Co-Morbidity Factors
Flap size (cm cm) Harvested and Weight Used (g)
Reconstruction Approach
Immediate Complications
Flap Outcome
1
59
Hysterectomy
No
30 12, 580
Bilateral SIEVs drainage
Partial loss
2
47
C/S
38 12, 710
Design higher
3
60
C/S
DM, Previous radiotherapy No
34 12, 675
Intraflap pedicle to pedicle anastomosis, contralateral breast reduction
Contralateral lateral zone arterial circulation compromised, venous congestion Contralateral lateral zone arterial circulation compromised No
Patient No.
Partial loss Complete survival
C/S, cesarean section.
FIGURE 1. A and B, A 60-year-old woman requested breast reconstruction because of a burn injury experienced in childhood. Scar contracture of right chest vail, breast hypoplasia, and nipple displacement were found. A, Anteroposterior view. B, Lateral view.
FIGURE 2. A, Preoperative markings were drawn for planned incision. The hemi-DIEP f lap would not be adequate for coverage, so the entire DIEP f lap was designed and harvested. B, The deep inferior epigastric perforator f lap was harvested.
FIGURE 3. Venous congestion developed intraoperatively in the contralateral lateral zone after anastomoses. Therefore, the contralateral SIEV (SIEV-c) was anastomosed to the ipsilateral SIEV (SIEV-i) with end-to-side fashion as a salvage procedure. S8
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Strategy for DIEP Flap with Midline Scar
FIGURE 4. Within the 12 hours postoperatively, some bluish area appeared and extended over parts of zone III and zone IV areas. Insufficient flap circulation was also found. The flap was reinset with a tension-free closure to promote flap circulation. Partial flap necrosis occurred 1 week postoperatively.
developed because of insufficient arterial perfusion crossing the midline scar to supply the contralateral lateral zone (Fig. 4). The partial f lap necrosis was debrided, and the residual f lap was reinset 7 days postoperatively. One revision of the f lap was performed 8 months postoperatively. The bilateral breasts contour 1 year postoperatively was ultimately acceptable (Figs. 5A, B).
Case 2 A 60-year-old nonsmoking woman with a lower midline abdominal scar presented for delayed right breast reconstruction status post radical mastectomy and radiotherapy 4 years prior. The DIEP f lap outline was marked, and the possible locations of perforators were detected by handheld Doppler probe. After the scar excision and contracture release, a large defect was created, and the entire DIEP f lap was needed for coverage (Fig. 6). Bilateral SIEVs were preserved and dissected. To augment the arterial perfusion and venous drainage across the midline scar, perforators of each side along with the deep inferior epigastric vessels were meticulously dissected and preserved. The left side inferior epigastric vessels, which was intended to be anastomosed to the internal mammary vessels, were dissected out both cephalically and caudally to gain the sufficient pedicle length. Then, the entire DIEP f lap, 34 12 cm, weighing 675 g, based on bilateral pedicles was disconnected from the abdomen. The extended distal ends of the left inferior epigastric vessels were anastomosed to the proximal ends of the right inferior epigastric vessels across the midline scar as an intraf lap pedicle-to-pedicle augmentation (Fig. 7A). After the successful intraflap microvascular
FIGURE 6. A 60-year-old nonsmoking woman with a lower midline abdominal scar because of previous gynecological procedure, underwent the delayed right breast reconstruction. Postmastectomy and radiotherapy for 4 years.
anastomosis, the f lap was transferred to the right chest for conventional end-to-end anastomosis between the proximal end of the left deep inferior epigastric vessels and internal mammary vessels. The f lap circulation was confirmed intraoperatively before f lap inset. The left-side reduction mammoplasty was performed for improved symmetry simultaneously. The postoperative f lap circulation was adequate across the midline including the contralateral lateral zone, with complete f lap survival achieved (Fig. 7B).
DISCUSSION Gill et al retrospectively reviewed 758 DIEP f lap cases for breast reconstruction over 10 years, concluding that previous abdominal scars were not a significant risk factor for f lap complications.11 Parrett et al had similar conclusions in their series of 104 f laps performed in the presence of previous abdominal scars.6 However, both series included all abdominal scar types, regardless of orientation or position. The specific outcomes of midline vertical scars of DIEP f lap or the complications associated with capturing territories beyond the midline scar were not addressed. The presence of vertical midline scars presents a technical challenge in flap harvest. Although the use of a hemi flap is the most conservative approach, the limited volume is not always ideal for the clinical scenario.
FIGURE 5. A and B, At a 1-year follow-up, the patient was satisfied with the symmetric and pleasing breast mounds with a secondary revised reconstruction. A, Anteroposterior view. B, Lateral view. * 2014 Lippincott Williams & Wilkins
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FIGURE 7. A and B, The extended distal stump of left deep inferior epigastric vessels were anastomosed to the proximal stump of right deep inferior epigastric vessels (contralateral side) across the midline scar as an intraf lap pedicle to pedicle arterial and venous augmentation. Complete f lap survival was achieved postoperatively.
Numerous surgical techniques have been reported for promoting TRAM f lap circulation across midline scars, including bipedicled f laps,12 retrograde, and contralateral supercharging.13Y15 Most of the procedures were complicated, and the definite effect remained controversial because of the limited cases. Heller et al15 reviewed 43 cases of patients with lower abdominal midline scars for TRAM f laps reconstruction. Various reconstructive approaches were described in his series, including free TRAM f laps incorporating tissue across the midline scar, free TRAM f laps designed higher, pedicled hemi-TRAM f lap plus contralateral free hemi-TRAM f lap, and bipedicled TRAM f laps. The majority of cases (26/43) used only hemif lap. Surprisingly, he found that tissue across midline scars could have good perfusion in some cases, making the territories suitable for reconstruction.15 It is hypothesized that angiogenesis occurs across the scars, allowing the territories across the midline scars to survive as a random f lap. Other authors reported that angiogenesis involving scar tissues can increase the microvascular density in the healing tissue.16 Han et al used more superiorly-located f laps in a rats model, finding that a midline abdominal scar could provide benefits similar to a delay with increasing size and density of the subdermal plexus.17 Conversely, Sano et al reported that contralateral hemif laps across the midline scar were all nonviable in a rat model.4 Midline abdominal scars were thus considered a relative contraindication for abdominal-based autologous reconstruction.2
In our series, we observed an average f lap use ratio of 68.75 T 8.95%, approaching two thirds of the entire abdominal f lap could be used, but with 30% complication in the contralateral lateral zone eventually developed partial f lap loss. The distance of the dominant perforator from the midline, not the number of perforators, is proposed as the determinant factor of the f lap reliability.2,18,19 Therefore, if the territory well perfused by the perforator does not provide adequate volume, bipedicles, additional supercharging or intraf lap pedicle to pedicle microvascular anastomoses are strongly recommended.20 In the clinical scenario where the entire DIEP f lap with an incorporated midline scar was harvested to reconstruct a large defect, venous congestion in the contralateral lateral zone is the key for developing partial f lap loss and fat necrosis. Cheng et al has described that the contralateral lateral zone in DIEP f laps were highly reliable even when a single perforator was incorporated.18 However, although bilateral pedicles can be intraf lap connected for augmented arterial perfusion and venous drainage, venous congestion in the contralateral lateral zone is still encountered where the superficial inferior epigastric vein (SIEV) is the dominant drainage. As we described in our first clinical case, salvage is attempted with anastomosis of the contralateral SIEV to the ipsilateral superficial system. Alternatively, another recipient venous drainage system can be used.21,22
FIGURE 8. The strategies for DIEP f lap breast reconstruction in patients with midline abdominal scars. A, indicates artery; DIEA-c, contralateral deep inferior epigastric artery; DIEA-i, ipsilateral deep inferior epigastric artery; DIEV-1, deep inferior epigastric vein 1; SIEV-i, ipsilateral superficial inferior epigastric vein; V, vein. S10
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In concordance with previous series, we found that tissue incorporated across the midline scar were viable in select cases. Although angiogenesis may extend across the scar tissue, the reliable distance remains unknown. The average f lap-used ratio in the group using the tissues across the midline scar was 68.75 T 8.95%. Although the contralateral lateral zone and possibly a part of contralateral medial zone were discarded in group 2, the complication rate was higher than group 1, which did not incorporate tissue across the midline. In our opinion, 2 cm across the midline could be reliable for f lap transfer. The strategies for DIEP f laps breast reconstruction in patients with lower midline scars are summarized in Figure 8. When lower midline abdominal scars are present, the hemi-DIEP f lap is the safest way but not absolutely needed. In select cases, the contralateral lateral zone and parts of the contralateral medial zone can be discarded, maintaining tissue across the midline with careful intraoperative f lap evaluation. In cases where the contralateral lateral zone is needed, intraf lap arterial and venous augmentation by connecting bilateral pedicles is strongly suggested. We can connect contralateral DIEA to ipsilateral DIEA, either with end-to-side fashion or end-to-ipsilateral DIEA distal end for the arterial insufficiency. If venous congestion is encountered, the contralateral SIEV can be anastomosed to the ipsilateral SIEV or DIEV as a salvage procedure.
CONCLUSIONS The hemi-DIEP f lap is a safer method for the patient with a lower abdominal midline scar, but it limits the available reconstructive volume. Carefully evaluating the tissue perfusion intraoperatively is crucial for deciding how much contralateral tissue should be discarded; 2 cm across the midline appears to be reliable in our experience. Intraf lap pedicle anastomoses is an assurance for using the entire DIEP f lap with an incorporated lower midline scar for large defect reconstruction. REFERENCES 1. Allen RJ, Treece P. Deep inferior epigastric perforator flap for breast reconstruction. Ann Plast Surg. 1994;32:32Y38. 2. Blondeel PN. One hundred free DIEP flap breast reconstructions: a personal experience. Br J Plast Surg. 1999;52:104Y111. 3. Garvey PB, Buchel EW, Pockaj BA, et al. DIEP and pedicled TRAM flaps: a comparison of outcomes. Plast Reconstr Surg. 2006;117:1711Y1719; discussion 1720Y1711. 4. Sano K, Hallock GG, Rice DC. A vertical midline scar is a ’high-risk’ factor for maximum survival of the rat TRAM flap. Ann Plast Surg. 2003;51:403Y408.
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Strategy for DIEP Flap with Midline Scar
5. Hsieh F, Kumiponjera D, Malata CM. An algorithmic approach to abdominal flap breast reconstruction in patients with pre-existing scarsYresults from a single surgeon’s experience. J Plast Reconstr Aesthet Surg. 2009;62:1650Y1660. 6. Parrett BM, Caterson SA, Tobias AM, et al. DIEP flaps in women with abdominal scars: are complication rates affected? Plast Reconstr Surg. 2008;121:1527Y1531. 7. Dragu A, Unglaub F, Wolf MB, et al. Scars and perforator-based flaps in the abdominal region: a contraindication? Can J Surg. 2010;53:137Y142. 8. Henry SL, Chang CC, Misra A, et al. Inclusion of tissue beyond a midline scar in the deep inferior epigastric perforator flap. Ann Plast Surg. 2011;67: 251Y254. 9. Henry SL, Cheng MH. A call for clarity in TRAM/DIEP zones. Plast Reconstr Surg. 2010;125:210eY211e. 10. Huang JJ, Chao LF, Wu CW, et al. Simultaneous scarless contralateral breast augmentation during unilateral breast reconstruction using bilateral differentially split DIEP flaps. Plast Reconstr Surg. 2011;128:593eY604e. 11. Gill PS, Hunt JP, Guerra AB, et al. A 10-year retrospective review of 758 DIEP flaps for breast reconstruction. Plast Reconstr Surg. 2004;113:1153Y1160. 12. Wagner DS, Michelow BJ, Hartrampf CR Jr. Double-pedicle TRAM flap for unilateral breast reconstruction. Plast Reconstr Surg. 1991;88:987Y997. 13. Pennington DG, Nettle WJ, Lam P. Microvascular augmentation of the blood supply of the contralateral side of the free transverse rectus abdominis musculocutaneous flap. Ann Plast Surg. 1993;31:123Y126; discussion 126Y127. 14. Semple JL. Retrograde microvascular augmentation (turbocharging) of a single-pedicle TRAM flap through a deep inferior epigastric arterial and venous loop. Plast Reconstr Surg. 1994;93:109Y117. 15. Heller L, Feledy JA, Chang DW. Strategies and options for free TRAM flap breast reconstruction in patients with midline abdominal scars. Plast Reconstr Surg. 2005;116:753Y759; discussion 760Y751. 16. Brown NJ, Smyth EA, Cross SS, et al. Angiogenesis induction and regression in human surgical wounds. Wound Repair Regen. 2002;10:245Y251. 17. Han S, Sup Eom J, Ho Kim D. Effects of the abdominal midline incision on the survival of the transverse rectus abdominis musculocutaneous flap in rat model. Ann Plast Surg. 2003;50:171Y176. 18. Cheng MH, Robles JA, Ulusal BG, et al. Reliability of zone IV in the deep inferior epigastric perforator flap: a single center’s experience with 74 cases. Breast. 2006;15:158Y166. 19. Heitmann C, Felmerer G, Durmus C, et al. Anatomical features of perforator blood vessels in the deep inferior epigastric perforator flap. Br J Plast Surg. 2000;53:205Y208. 20. Schoeller T, Wechselberger G, Roger J, et al. Management of infraumbilical vertical scars in DIEP-flaps by crossover anastomosis. J Plast Reconstr Aesthet Surg. 2007;60:524Y528. 21. Villafane O, Gahankari D, Webster M. Superficial inferior epigastric vein (SIEV): ‘lifeboat’ for DIEP/TRAM flaps. Br J Plast Surg. 1999;52:599. 22. Ali R, Bernier C, Lin YT, et al. Surgical strategies to salvage the venous compromised deep inferior epigastric perforator flap. Ann Plast Surg. 2010;65:398Y406.
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