No Skin Paddle, No Problem: Burying Deep Inferior Epigastric Artery Flaps in the Immediate Setting is Safe in Select Patient Populations

Abstract

Background In appropriately selected patients, it may be possible to fully bury breast free flaps deep to the mastectomy skin flaps. Because this practice forgoes the incorporation of a monitoring skin paddle for the flap, and thus limits the ability for physical exam, it may be associated with an increased risk of flap loss or other perfusion-related complications, such as fat necrosis. We hypothesized that fully de-epithelialized breast free flaps were not associated with an increased complication rate and reduced the need for future revision surgery.

Methods A single-institution retrospective review of 206 deep inferior epigastric artery (DIEP) flaps in 142 patients was performed between June 2016 and September 2021. Flaps were grouped into buried or nonburied categories based on the absence or presence of a monitoring paddle. Patient-reported outcomes were assessed postoperatively using the BREAST-Q breast reconstruction module. Electronic medical record data included demographics, comorbidities, flap characteristics, complications, and revision surgery.

Results The buried flap patients (N = 46) had a lower median body mass index (26.9 vs 30.3, p = 0.04) and a lower rate of hypertension (19.5 vs. 37.5%, p = 0.04) compared with nonburied flap patients (N = 160). Burying flaps was more likely to be adopted in skin-sparing mastectomy or nipple-sparing mastectomy (p = 0.001) and in an immediate or a delayed–immediate fashion (p = 0.009). There was one flap loss in the nonburied group; complication rates were similar. There was a significantly greater revision rate in the nonburied flap patients (92 vs. 70%; p = 0.002). Buried flap patients exhibited a greater satisfaction with breasts (84.5 ± 13.4 vs. 73.9 ± 21.4; p = 0.04) and sexual satisfaction (73.1 ± 22.4 vs. 53.7 ± 29.7; p = 0.01) compared with nonburied flap patients.

Conclusion Burying breast free flaps in appropriately selected patients does not appear to have a higher complication rate when compared with flaps with an externalized monitoring paddle. Furthermore, this modification may be associated with a better immediate aesthetic outcome and improved patient satisfaction, as evidenced by a lower rate of revision surgery and superior BREAST-Q scores among buried DIEP flaps.

Keywords

breast reconstruction - surgical flaps - breast cancer

Publikationsverlauf

Eingereicht: 06. Dezember 2023

Angenommen: 15. April 2024

Accepted Manuscript online:
06. Mai 2024

Artikel online veröffentlicht:
31. Mai 2024

• References

• 1 Spear SL, Davison SP. Aesthetic subunits of the breast. Plast Reconstr Surg 2003; 112 (02) 440-447
• 2 Bailey SH, Saint-Cyr M, Oni G. et al. Aesthetic subunit of the breast: an analysis of women's preference and clinical implications. Ann Plast Surg 2012; 68 (03) 240-245
• 3 Mallucci P, Branford OA. Concepts in aesthetic breast dimensions: analysis of the ideal breast. J Plast Reconstr Aesthet Surg 2012; 65 (01) 8-16
• 4 Smith JM, Boukovalas S, Chang EI. et al. Analysis of breast aesthetic revision procedures after unilateral abdominal-based free-flap breast reconstruction: a single-center experience with 1251 patients. Plast Reconstr Surg Glob Open 2023; 11 (03) e4861
• 5 Salibian AA, Bekisz JM, Frey JD. et al. Comparing outcomes between stacked/conjoined and non-stacked/conjoined abdominal microvascular unilateral breast reconstruction. Microsurgery 2021; 41 (03) 240-249
• 6 Disa JJ, Cordeiro PG, Hidalgo DA. Efficacy of conventional monitoring techniques in free tissue transfer: an 11-year experience in 750 consecutive cases. Plast Reconstr Surg 1999; 104 (01) 97-101
• 7 Rose V, Cooper L, Pafitanis G, Hogben K, Sharma A, Din AH. Single-stage buried autologous breast reconstruction (BABR). J Plast Reconstr Aesthet Surg 2022; 75 (09) 2960-2969
• 8 Dunklebarger MF, McCrary H, King B. et al. Success of implantable doppler probes for monitoring buried free flaps. Otolaryngol Head Neck Surg 2022; 167 (03) 452-456
• 9 Poder TG, Fortier PH. Implantable Doppler in monitoring free flaps: a cost-effectiveness analysis based on a systematic review of the literature. Eur Ann Otorhinolaryngol Head Neck Dis 2013; 130 (02) 79-85
• 10 Levine SM, Snider C, Gerald G. et al. Buried flap reconstruction after nipple-sparing mastectomy: advancing toward single-stage breast reconstruction. Plast Reconstr Surg 2013; 132 (04) 489e-497e
• 11 Rozen WM, Whitaker IS, Wagstaff MJD, Audolfsson T, Acosta R. Buried free flaps for breast reconstruction: a new technique using the Cook-Swartz implantable Doppler probe for postoperative monitoring. Plast Reconstr Surg 2010; 125 (04) 171e-172e
• 12 Chadwick SL, Khaw R, Duncan J, Wilson SW, Highton L, O'Ceallaigh S. The use of venous anastomotic flow couplers to monitor buried free DIEP flap reconstructions following nipple-sparing mastectomy. JPRAS Open 2019; 23: 50-54
• 13 Cho BC, Shin DP, Byun JS, Park JW, Baik BS. Monitoring flap for buried free tissue transfer: its importance and reliability. Plast Reconstr Surg 2002; 110 (05) 1249-1258
• 14 Brendler-Spaeth CI, Jacklin C, See JL, Roseman G, Kalu PU. Autologous breast reconstruction in older women: a retrospective single-centre analysis of complications and uptake of secondary reconstructive procedures. J Plast Reconstr Aesthet Surg 2020; 73 (05) 856-864
• 15 Nelson JA, Voineskos SH, Qi J. et al. Elective revisions after breast reconstruction: results from the mastectomy reconstruction outcomes consortium. Plast Reconstr Surg 2019; 144 (06) 1280-1290
• 16 Santosa KB, Qi J, Kim HM, Hamill JB, Wilkins EG, Pusic AL. Long-term patient-reported outcomes in postmastectomy breast reconstruction. JAMA Surg 2018; 153 (10) 891-899
• 17 Chang EI, Chang EI, Soto-Miranda MA. et al. Comprehensive evaluation of risk factors and management of impending flap loss in 2138 breast free flaps. Ann Plast Surg 2016; 77 (01) 67-71
• 18 Chang EI, Ibrahim A, Zhang H. et al. Deciphering the sensitivity and specificity of the implantable Doppler probe in free flap monitoring. Plast Reconstr Surg 2016; 137 (03) 971-976
• 19 Levine SM, Snider C, Gerald G. et al. Buried flap reconstruction after nipple-sparing mastectomy: advancing toward single-stage breast reconstruction. Plast Reconstr Surg 2013; 132 (04) 489e-497e
• 20 Haddock NT, Garza R, Boyle CE, Teotia SS. Observations from implementation of the ERAS protocol after DIEP flap breast reconstruction. J Reconstr Microsurg 2022; 38 (06) 506-510
• 21 Rodnoi P, Teotia SS, Haddock NT. Economic impact of refinements in ERAS pathways in DIEP flap breast reconstruction. J Reconstr Microsurg 2022; 38 (07) 524-529
• 22 Shen AY, Lonie S, Lim K, Farthing H, Hunter-Smith DJ, Rozen WM. Free flap monitoring, salvage, and failure timing: a systematic review. J Reconstr Microsurg 2021; 37 (03) 300-308
• 23 Lee MK, Park HY, Park JW, Mun GH, Woo KJ. Three-dimensional volume changes of the reconstructed breast following DIEP flap breast reconstruction. J Reconstr Microsurg 2023; 39 (06) 427-434