Multiple techniques exist for transfer of lower abdominal tissue for breast reconstruction:
pedicled and free TRAMs, DIEP, or SIEA flaps. However, the ideal vascularity in cases
of previous abdominal surgery has not been explicitly defined. The authors presented
their past 3-year experience in breast reconstruction using lower abdominal tissue,
and provided an algorithm for the determination of the preferred flap in cases of
previous abdominal scarring from Pfannensteil, McBurney, Kocher, midline, paramedian,
or laparoscopic incisions.
Preoperatively, it was anticipated that all patients would undergo free tissue transfer
(DIEP flap preferred). Microvascular transfer was possible in all but two patients
(lack of recipient vessels in a severely irradiated chest and a lower lateral paramedian
incision for appendectomy that had transected the deep inferior epigastrics). No other
scars, including Kocher and McBurney incisions, precluded free tissue transfer. Previous
laparascopic surgery had no effect on choice of flap.
Pfannensteil incisions were of importance: SIEAs were universally divided, whereas
DIEAs were not. However, lower lateral and mid-to-low medial row perforators were
not reliable perforators on which to base DIEP flaps, and resulted in inadequate flap
vascularity, increased incidence of fat necrosis, need for venous supercharge from
the superficial system, or conversion to free TRAM. When a lower midline incision
was present, medial row perforators were less likely to be available for supplying
the DIEP flap, so that lateral row perforators were usually selected.
This summary was used to develop guidelines for flap dissection and selection for
breast reconstruction in cases of previous abdominal surgery.
