T. Tomouk1, A. T. Mohan2,3,4, A. Azizi1, E. Conci1, E. B. Brickley5, C. M. Malata2,6 1University Of Cambridge,School Of Clinical Medicine,Cambridge, CAMBRIDGESHIRE, United Kingdom 2Addenbrooke’s University Hospital,Plastic And Reconstructive Surgery Department,Cambridge, CAMBRIDGESHIRE, United Kingdom 3Mayo Clinic,Rochester, MN, USA 4Restoration Of Appearance And Function Charitable Trust (RAFT),Research Fellow,London, LONDON, United Kingdom 5University Of Cambridge,Department Of Public Health And Primary Care,Cambridge, CAMBRIDGESHIRE, United Kingdom 6Postgraduate Medical Institute At Anglia Ruskin University,Cambridge And Chelmsford, CAMBRIDGESHIRE, United Kingdom
Introduction: The use of abdominal tissue in post-mastectomy autologous breast reconstruction is a popular choice among reconstructive surgeons. Abdominal perforator flaps have lower donor site morbidity compared to the Transverse Rectus Abdominis Myocutaneous (TRAM) flap, though complications such as seroma formation, delayed healing, fat necrosis and abdominal wall weakness may still occur. This is the first study to evaluate donor complications based on the type of Deep Inferior Epigastric Artery Perforator (DIEP) surgical procedure and compares unilateral, bilateral and bipedicled breast reconstructions.
Methods: A retrospective chart review was conducted of all women undergoing rib-preserving abdominal free flap breast reconstruction at a University Hospital between 2008-2015 by a single surgeon. Data were collected on patient demographics, operative details and postoperative complications, with a specific focus on donor site morbidity. Patients who underwent Superficial Inferior Epigastric Artery (SIEA) flaps (n=20) or had incomplete information (n=27) were excluded.
Results: Of 177 patients identified, a total of 130 patients (73.4%) were included in this study and divided into three groups for comparison: unilateral (n=93), bilateral (n=19) and bipedicled (n=18). Age, smoking history, radiotherapy and chemotherapy exposure were similar across the three groups and did not influence complication risk. Body Mass Index (BMI) was significantly lower in the bipedicled group, as expected (p<0.01, Kruskal-Wallis test). Wound dehiscence was greatest in the unilateral group at 22.6%, compared to 15.8% in the bilateral, and 5.6% in bipedicled group (p=0.23, Chi-squared Test). Seroma rates were highest in the bilateral group at 63.2% versus 48.4% in the unilateral group and 33.3% in the bipedicled group (p=0.19, Chi-squared Test). Fat necrosis occurred in 12.9% of unilateral, 10.5% of bilateral and 0% of the bipedicled reconstructions. Prevalence of abdominal bulge was low in all three groups (≤6.5%). In univariate analyses and relative to the unipedicled, unilateral group, the overall odds of complication was approximately two-fold higher in the bilateral group (Odds ratio (95% CI): 2.16 (0.66, 7.04)), and almost halved in the bipedicled group (Odds ratio (95% CI): 0.46 (0.17, 1.28)); however these associations had wide confidence intervals and attenuated upon further adjustment. Complications were managed conservatively without recourse to surgery in 68.8%.
Conclusion: DIEP flap breast reconstruction is still fraught with donor site morbidity although most complications are minor and comprise predominantly seroma, delayed healing and fat necrosis. These are often managed conservatively. While bipedicled DIEPs were reserved for lower BMI patients they, like bilateral breast reconstructions, can be performed safely without undue increase in donor site complications. Our study suggests that the type of DIEP flap does not impact donor site morbidity.