Stacked Free SIEA/DIEP Flap for Unilateral Breast Reconstruction in a Thin Patient with an Abdominal Vertical Midline Scar

Nowadays, free microvascular tissue transfer has become a routine practice in breast reconstructive surgery.[1] The lower abdominal tissue is hailed as the gold standard in breast reconstruction.[2] Although the selection of flaps available from the lower abdomen continues to evolve,[3] [4] [5] breast reconstruction with autologous tissue in slender women with abdominal midline scars is still a challenge. The opportunity to use stacked flaps or implants with flaps for unilateral breast reconstruction in thin patients has previously been described.[6] [7] [8] [9] [10] [11] [12] [13] [14] [15] We report an unusual case of a young, slender woman with a lower abdominal vertical midline scar and a previous failed right breast reconstruction with latissimus dorsi (LD) flap plus implant and contralateral left breast augmentation. This patient was successfully treated with a stacked free superficial inferior epigastric artery/deep inferior epigastric artery perforator (SIEA/DIEP) flap to correct the lack of skin and volume to match the contralateral augmented breast. To our knowledge, this is the first description of stacked free flap using a hemi-SIEA flap combined with a hemi-DIEP flap for unilateral breast reconstruction. This surgical option seems not to be previously highlighted in the literature.

A 36-year-old, nonsmoking black woman presented with a 7-year history of breast surgeries performed at another institution. In February 1999, she had a grade III breast cancer with surrounding focal ductal carcinoma in situ (DCIS), without lymph node involvement. At that time, right skin sparing mastectomy with axillary clearance followed by immediate breast reconstruction with LD flap plus implant was performed. She received adjuvant chemotherapy and radiotherapy. After 6 months, she underwent nipple/areola complex reconstruction with a local flap and tattooing. Nine months after mastectomy and immediate reconstruction, she developed a local recurrence in the right axillary tail region, which was excised successfully. Two years after, she had a contralateral left subglandular breast augmentation with a silicone-gel implant to improve the breast symmetry. Thereafter, she had two capsulectomies and changes of implant in the right reconstructed breast due to Baker's grade III capsular contracture. After the last implant change, she developed an infection, and the implant was removed from the reconstructed breast.

At presentation to our clinic, she had a shrunken reconstructed right breast with the LD flap skin paddle recognizable in the lower pole and a size 36 DD contralateral augmented breast with grade II ptosis (Fig. [1]). Scars in the back and in the abdomen, from the umbilicus to the pubic tubercle, further to 9-year previous gynecologic surgery, were identified.

Figure 1 Preoperative views of the patient.

Use of autologous free tissue transfer from the gluteal region free superior gluteal artery perforator (SGAP) flap was offered to the patient in the first instance. She refused a buttock scar and further was keen to maintain the volume of the contralateral augmented breast. Hence, stacked free hemi-DIEP flaps[6] [9] were planned to maximize breast volume and projection and minimize donor site morbidity.

During surgical dissection, a reliable size of the superficial inferior epigastric vessels was found on the right side. The SIEA flap veins were found laterally and superficially to the artery. The SIEA flap vascular pedicle was dissected until its origin from the femoral vessels with a length of 6 cm. Proceeding forward, the left SIEA flap pedicle was found reliable as well, but a longer and a flow-through pedicle had to be available for a successful procedure. Hence, a contralateral left hemi-DIEP flap, based on two perforators, was harvested. The pedicle was 13 cm in length until the proximal perforator. An additional 5 cm of the medial division of the deep inferior epigastric artery was harvested distal to the perforators. The two flaps were anastomosed in series using the left side superficial inferior epigastric vessels and the distal end of the medial division of the right side deep inferior epigastric vessels (Fig. [2]). End-to-end anastomosis was performed on the table while the abdomen was closed. Both flaps, connected together, were sutured and inset in the right breast filling the native skin envelope in the upper quadrants and contributing to shape and volume with the abdominal skin in the lower quadrants. This stacked free flap was perfused anastomosing the left hemi-DIEP flap pedicle with the thoraco-dorsal vessels, which were found intact and patent in the right axilla, despite the previous LD flap harvesting. The entire procedure was concluded in less than 5 hours. The postoperative period was uneventful, and the patient was discharged after 6 days. After 18 months, a long-lasting satisfactory result without donor site complications was documented (Fig. [3]).

Figure 2 Free stacked SIEA/DIEP flap: (A) shaping, (B) anastomoses. TDA, thoraco-dorsal artery; TDV, thoraco-dorsal vein; DIEA, deep inferior epigastric artery; DIEV, deep inferior epigastric vein; SIEA, superficial inferior epigastric artery; SIEV, superficial inferior epigastric vein.

Figure 3 Postoperative views after 18 months follow-up.

In the current case, implants and LD flap had already been used to reconstruct the right breast after mastectomy. The patient had contralateral breast augmentation, implant infection on the right side, preexisting vertical subumbilical scar, and skin loss in the right mammary region. Moreover, she was keen to maintain the contralateral breast size and she refused buttock scars. A stacked free abdominal flap was considered a good option to optimize the breast reconstruction outcome. The favorable intraoperative finding of a reliable SIEA pedicle led to harvest of a stacked free SIEA/DIEP flap. The need of longer pedicle, suitable for two end-to-end anastomoses in series, was essential in the flap planning. The use of a contralateral hemi-DIEP flap allowed having a longer pedicle also providing a flow-through conduit to perfuse the right SIEA flap. There was no need to expose the internal mammary vessels because an intact and patent thoraco-dorsal pedicle was available in the right axilla. The major drawbacks of this kind of flap are the complexity of the anastomoses procedure and the inconstant and limited length and size of the SIEA pedicle.[4] [16] [17] [18] [19] [20] Compared with both stacked free transverse rectus abdominis myocutaneous (TRAM) and DIEP flaps, the finding of a reliable SIEA pedicle allows an easier and faster harvesting of a lower abdominal hemi-flap reducing significantly the donor site morbidity. The successful result confirms that abdominal stacked free flaps are a complex but effective solution in complicated cases.

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