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Free DIEP and TRAM Flaps Harvested with Perforators from both Branches of the Deep Inferior Epigastric Artery Result in Fewer Perfusion-Related Complications than Perforator Flaps Limited to a Single Branch
Patrick B. Garvey, M.D., F.A.C.S., Steven M. DelBello, B.S., Jun Liu, M.D., M.S., Steven J. Kronowitz, M.D., F.A.C.S., Charles E. Butler, M.D., F.A.C.S..
The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA.

INTRODUCTION: For patients who undergo breast reconstruction with deep inferior epigastric perforator (DIEP) or muscle-sparing free transverse rectus abdominis musculocutaneous (MS FTRAM) flaps, abdominal wall donor site and perfusion-related flap outcomes are similar, regardless of whether the flaps are based on a medial or a lateral branch of the deep inferior epigastric artery (DIEA). Surgeons often find it necessary to harvest both DIEA branches to optimize flap perfusion, yet no studies have compared outcomes between single and double DIEA branch flaps to support this practice. We hypothesized that patients undergoing breast reconstruction with free DIEP or MS FTRAM flaps based on perforators from a single DIEA branch would have a higher incidence of fat necrosis and a lower incidence of bulge/hernia than those undergoing reconstruction based on perforators from both DIEA branches.
METHODS: We evaluated all consecutive abdomen-based free flap breast reconstructions performed at a single institution between 2000 and 2011. We included Type II branching pattern DIEP or MS FTRAM flaps in which it could be clearly determined from which branches the perforators were harvested. Patients were grouped and compared on the basis of DIEA branch harvest (single vs. double), flap type (DIEP vs. MS FTRAM), and number of perforators included in the flap (1 vs. 2 vs. >3). Primary outcome measures were abdominal bulge/hernia and perfusion-related complications (fat necrosis and partial flap necrosis), which were determined by review of comprehensive follow-up records, including physical examination, radiographic, and pathologic evaluation data.
RESULTS: We identified 1418 breast reconstructions in 1127 patients that met study inclusion criteria: 693 double- and 725 single-branch flaps. Mean follow-up was 3.6 ± 2.6 years. There was no difference in the overall complication rates between the double- vs. single-branch flaps (27.9% vs. 31.7%; p=0.11). The incidences of fat necrosis (4.2% vs. 8.8%; p<0.01) and partial flap necrosis (1.4% vs. 3.1%; p=0.03) were significantly lower for double- vs. single-branch flaps. The incidence of bulge was similar (3.6% vs. 3.5%, p=0.87), whereas hernias occurred more frequently (3.2% vs. 1.8%, p=0.06) in the double- vs. single-branch flaps, respectively. DIEP and MS FTRAM flaps had similar rates of overall complications (29.6% vs. 30.0%; p=0.87), fat necrosis (7.7% vs. 6.0%; p=0.21), and bulge (3.6% vs. 3.5%; p=0.86), respectively. However, DIEP flaps had significantly more partial flap necrosis (3.4% vs. 1.7%; p=0.04) and fewer hernias (1.2% vs. 3%; p=0.03) than MS FTRAM flaps. Reconstructions using flaps with 1 perforator had a significantly higher overall complication rate (37.2%) than those with 2 and >3 perforators (28.9% and 27.5%, respectively; p=0.05). However, perforator number was NOT associated with significant differences in rates of fat necrosis, partial flap necrosis, hernia, or bulge.
CONCLUSIONS: This is the largest study to date comparing perfusion-related and donor-site outcomes of abdominal-based free flap breast reconstruction. Double-branch flaps had significantly lower rates of perfusion-related complications than single-branch flaps, without significant added donor site morbidity. Therefore, surgeons should primarily base decisions regarding the quality and quantity of perforators selected on vascular perfusion quality, without overestimating the effects on donor site morbidity.


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