Download PDF
J Reconstr Microsurg 2019; 35(06): 411-416
DOI: 10.1055/s-0038-1677013
Original Article
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

The “Dual-Plane” DIEP Flap: Measuring the Effects of Superficial Arterial and Venous Flow Augmentation on Clinical Outcomes

Hani Sbitany
1   Division of Plastic and Reconstructive Surgery, University of California San Francisco, San Francisco, California
,
Rachel Lentz
1   Division of Plastic and Reconstructive Surgery, University of California San Francisco, San Francisco, California
,
Merisa Piper
1   Division of Plastic and Reconstructive Surgery, University of California San Francisco, San Francisco, California
› Author Affiliations Funding No funding was provided for the data collection or writing of this manuscript.
Further Information

Publication History

22 July 2018

11 November 2018

Publication Date:
07 January 2019 (online)

Also available at
    Permissions and Reprints

Abstract

Background Deep inferior epigastric perforator (DIEP) flaps are routinely elevated on a single dominant perforator from the deep epigastric vascular system. However, the single perforator may not always perfuse an entire flap adequately, particularly suprascarpal tissue. We often perform “dual-plane” single perforator DIEP flaps by rerouting the superficial (SIEA/V) system directly into a branch of the deep (DIEA/V) vascular system pedicle, thus allowing both systems to contribute and enhance flap perfusion.

Methods A prospectively collected database of patients undergoing microvascular breast reconstruction was reviewed for patients undergoing “dual-plane” DIEP flaps. These were matched to a similar cohort of patients undergoing “traditional” single perforator DIEP free flaps over the same time period. Treatment demographics and flap-specific morbidity outcomes were assessed, including performance in the setting of radiation.

Results Over 2 years, 23 “dual-plane” DIEP flaps were performed (15 patients), compared with 35 single-perforator “traditional” DIEP flaps (23 patients). Rates of delayed healing were similar between both cohorts (2.9 vs. 4.3%, p = 0.28). Rates of palpable fat necrosis were significantly lower in “dual-plane” DIEP flaps compared with “traditional” flaps (0 vs. 14.3%, p = 0.03). Rates of clinically palpable fat necrosis following radiation were significantly lower in the “dual-plane” flaps (4.3 vs. 40%, p = 0.02).

Conclusion The “dual-plane” DIEP flap is one we routinely consider in our algorithm, as it allows for full preservation of functional abdominal musculature, and offers enhanced flap perfusion by incorporating both the deep and superficial (dominant) vascular systems. This results in lower fat necrosis rates, particularly in the setting of post-reconstruction radiation.

Keywords

breast reconstruction - microsurgery - supercharging

Note

This study was presented at the American Society of Reconstructive Microsurgery (ASRM) Annual Meeting. Scottsdale, Arizona. January 2016.


Financial Disclosures

None of the authors have any disclosures related to the content of this manuscript.


Study Classification

Case-Control.


Author Contribution

Dr. Hani Sbitany: Study idea conception, study design, data collection, surgical case collection, and writing of manuscript.


Dr. Rachel Lentz: Study idea conception, study design, and review of manuscript.


Dr. Merisa Piper: Study idea conception, study design, and writing of manuscript.


Letter to this article:

The “Dual-Plane” DIEP Flap: Measuring the Effects of Superficial Arterial and Venous Flow Augmentation on Clinical OutcomesJ Reconstr Microsurg 2019; 35(06): e1-e1
DOI: 10.1055/s-0039-1700552

 

  • References

  • 1 Serletti JM, Fosnot J, Nelson JA, Disa JJ, Bucky LP. Breast reconstruction after breast cancer. Plast Reconstr Surg 2011; 127 (06) 124e-135e
    CrossrefPubMedSearch in Google Scholar
  • 2 Nahabedian MY, Momen B, Galdino G, Manson PN. Breast reconstruction with the free TRAM or DIEP flap: patient selection, choice of flap, and outcome. Plast Reconstr Surg 2002; 110 (02) 466-475 , discussion 476–477
    CrossrefPubMedSearch in Google Scholar
  • 3 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 (04) 1153-1160
    CrossrefPubMedSearch in Google Scholar
  • 4 Tønseth KA, Hokland BM, Tindholdt TT, Abyholm FE, Stavem K. Quality of life, patient satisfaction and cosmetic outcome after breast reconstruction using DIEP flap or expandable breast implant. J Plast Reconstr Aesthet Surg 2008; 61 (10) 1188-1194
    CrossrefPubMedSearch in Google Scholar
  • 5 Rozen WM, Ashton MW, Taylor GI. Reviewing the vascular supply of the anterior abdominal wall: redefining anatomy for increasingly refined surgery. Clin Anat 2008; 21 (02) 89-98
    CrossrefPubMedSearch in Google Scholar
  • 6 Rozen WM, Pan WR, Le Roux CM, Taylor GI, Ashton MW. The venous anatomy of the anterior abdominal wall: an anatomical and clinical study. Plast Reconstr Surg 2009; 124 (03) 848-853
    CrossrefPubMedSearch in Google Scholar
  • 7 Yamamoto Y, Sakurai H, Nakazawa H, Nozaki M. Effect of vascular augmentation on the haemodynamics and survival area in a rat abdominal perforator flap model. J Plast Reconstr Aesthet Surg 2009; 62 (02) 244-249
    CrossrefPubMedSearch in Google Scholar
  • 8 Mirzabeigi MN, Smartt JM, Nelson JA, Fosnot J, Serletti JM, Wu LC. An assessment of the risks and benefits of immediate autologous breast reconstruction in patients undergoing postmastectomy radiation therapy. Ann Plast Surg 2013; 71 (02) 149-155
    CrossrefPubMedSearch in Google Scholar
  • 9 Pien I, Caccavale S, Cheung MC. , et al. Evolving trends in autologous breast reconstruction: is the deep inferior epigastric artery perforator flap taking over?. Ann Plast Surg 2016; 76 (05) 489-493
    CrossrefPubMedSearch in Google Scholar
  • 10 Rozen WM, Ashton MW. The venous anatomy of the abdominal wall for deep inferior epigastric artery (DIEP) flaps in breast reconstruction. Gland Surg 2012; 1 (02) 92-110
    PubMedSearch in Google Scholar
  • 11 Sadik KW, Pasko J, Cohen A, Cacioppo J. Predictive value of SIEV caliber and superficial venous dominance in free DIEP flaps. J Reconstr Microsurg 2013; 29 (01) 57-61
    PubMedSearch in Google Scholar
  • 12 Sbitany H, Mirzabeigi MN, Kovach SJ, Wu LC, Serletti JM. Strategies for recognizing and managing intraoperative venous congestion in abdominally based autologous breast reconstruction. Plast Reconstr Surg 2012; 129 (04) 809-815
    CrossrefPubMedSearch in Google Scholar
  • 13 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 (04) 398-406
    CrossrefPubMedSearch in Google Scholar
  • 14 Liu TS, Ashjian P, Festekjian J. Salvage of congested deep inferior epigastric perforator flap with a reverse flow venous anastomosis. Ann Plast Surg 2007; 59 (02) 214-217
    CrossrefPubMedSearch in Google Scholar
  • 15 Tutor EG, Auba C, Benito A, Rábago G, Kreutler W. Easy venous superdrainage in DIEP flap breast reconstruction through the intercostal branch. J Reconstr Microsurg 2002; 18 (07) 595-598
    Thieme ConnectPubMedSearch in Google Scholar
  • 16 Bartlett EL, Zavlin D, Menn ZK, Spiegel AJ. Algorithmic approach for intraoperative salvage of venous congestion in DIEP flaps. J Reconstr Microsurg 2018; 34 (06) 404-412
    Thieme ConnectPubMedSearch in Google Scholar
  • 17 Chevray PM. Breast reconstruction with superficial inferior epigastric artery flaps: a prospective comparison with TRAM and DIEP flaps. Plast Reconstr Surg 2004; 114 (05) 1077-1083 , discussion 1084–1085
    PubMedSearch in Google Scholar
  • 18 Garvey PB, Clemens MW, Hoy AE. , et al. Muscle-sparing TRAM flap does not protect breast reconstruction from postmastectomy radiation damage compared with the DIEP flap. Plast Reconstr Surg 2014; 133 (02) 223-233
    CrossrefPubMedSearch in Google Scholar
  • 19 Colohan S, Maia M, Langevin CJ. , et al. The short- and ultrashort-pedicle deep inferior epigastric artery perforator flap in breast reconstruction. Plast Reconstr Surg 2012; 129 (02) 331-340
    CrossrefPubMedSearch in Google Scholar