1; P. Hyza
2; N. Monni
1; J. Lonigro
1; I. Stupka
1; A. Dimatteo
1; U. Choudry
Clinic of Plastic and Aesthetic Surgery, Masaryk University, Brno
1; Clinic of Plastic and Aesthetic Surgery, St. Anne University Hospital, Brno, Czech Republic, and
2; Division of Plastic Surgery, Department of Surgery, University of Minnesota, Minneapolis, USA
Vyšlo v časopise:
ACTA CHIRURGIAE PLASTICAE, 50, 3, 2008, pp. 71-75
free tissue transfer for breast reconstruction is a well-established
and reliable procedure. Breast reconstruction with free abdominal
flaps enables a plastic surgeon to obtain a natural shape
of the reconstructed mound and stable long term results (2, 3). The
donor site morbidity is usually acceptable and well tolerated,
especially when a free muscle sparing-TRAM or a DIEP flap
is used (5, 8). However,
selection of the patient is very important, and the possibility of
other reconstructive options should be taken into account based on
the patient’s preferences, co-morbid conditions, oncology status,
potential size of the reconstructed breast and previous surgeries in
the abdominal area (1).
bilateral skin sparing or subcutaneous mastectomy with immediate
reconstruction is a surgical option considered by many patients
with high risk of developing breast cancer. BRCA mutations, very
strong familial history and/or multifocal pre-malignant changes in
the breast parenchyma, along with contra-lateral breast cancer, are
some of the reasons why women opt for prophylactic mastectomies. Both
autologous and implant-based breast reconstruction is available to
these patients. Many patients prefer reconstruction of the breast
with autologous tissue (4, 7, 9–11). Patients with adequate
abdominal tissue and small/medium breast size are able to have the
breast reconstructed with a hemi-abdominal flap alone. This
enables symmetric reconstruction utilizing the abdominal flap
composed of only vascular areas I and II of the DIEP flap.
Usually the peripheral zones III and IV are discarded. However, it is
possible to bank the unused hemi-abdominal flap for later use instead
of discarding it. This “spare” flap could then potentially be
used for reconstructing the contra-lateral breast in patients who
later develop breast cancer in that breast, or be used as a salvage
flap for a failed primary reconstruction. We describe this
surgical approach to unilateral breast reconstruction in patients
with unilateral breast cancer; patients who are at high risk for
developing contra-lateral breast cancer but reluctant to undergo
simultaneous prophylactic mastectomy of the opposite breast; or
patients for whom the risk of free flap failure is high.
describe the technique of preservation of a spare hemi-abdominal
flap in two patients. Both patients underwent unilateral mastectomy
with immediate reconstruction and were at high risk of developing
breast carcinoma in the opposite breast; however, they opted not to
have a prophylactic mastectomy of the unaffected breast. They
also had ample abdominal tissue to reconstruct the affected breast
with only half of the abdominal tissue. Instead of discarding zones
III and IV, the contra-lateral, unused hemi-abdominal flap was
banked. This portion of the flap was deepithelialized and buried
under the abdominal closure. This “spare” flap could potentially
be used in case of future requirement for contra-lateral breast
reconstruction or as a bailout flap. The patients were
preoperatively informed about the possibility of developing a visible
asymmetry of their abdomen caused by the buried extra tissue. It was
explained to them that, if desired, liposuction could be performed in
future to achieve symmetry.
1 was a 55-year-old female who underwent a right
subcutaneous mastectomy for Grade 1 ductal carcinoma in situ and
immediate unilateral breast reconstruction (Fig. 1). The patient was
at high risk for the development of a metachronous
contra-lateral breast carcinoma due to her strong familial history.
Despite counselling, she opted not to have a prophylactic
contra-lateral mastectomy. A right DIEP hemi-abdominal flap was
harvested in the described manner for bilateral reconstructions (Fig.
2). The blood supply was based on two lateral row perforators. The
flap was transferred to the recipient site, and the breast was
reconstructed. Microsurgical anastomosis was performed to the
internal mammary artery and vein in the 4th
inter-costal space. The unused left hemi-abdominal flap was
de-epithelialized and buried underneath the usual
abdominoplasty closure (Fig. 3 a–c).
the end of the surgery the flap looked pale, with slow capillary
refill. On re-exploration there was visible and palpable flow through
both arterial and venous anastomoses. The pedicle did not show any
signs of thrombosis, and no obvious damage to the perforators was
observed. Vasospasm of the microcirculation was deemed the problem,
and we administered Rheodextran 10% (Infusia,
Czech Republic) in continuous infusion (30 ml per hour). During
immediate postoperative care the circulation in the flap continued to
show signs of ischemia. On the second postoperative day we surgically
explored the anastomoses. Both arterial and venous anastomoses were
patent, and detailed observation of the pedicle did not show any
signs of damage or thrombosis. Persistent signs of ischemia forced us
to perform a second flap exploration on the third postoperative
day. This time the flap was removed after it was established that
there was no microcirculation despite a patent pedicle artery
and vein. There was, however, arterial thrombosis of both of the
perforators distal to their take-off from the main pedicle. The
specimens taken from the flap and different parts of the pedicle
vessels were sent for histological examination, which revealed
thrombosis of small vessels in the periphery of the flap, necrotizing
vasculitis and necrosis of the sweat glands. As the stem of the
pedicle was thrombus free and the main anastomoses of the deep
inferior epigastric vessels to the intercostal vessels were patent,
we left the main vessels of the flap pedicle in situ, and they served
as vascular grafts. Breast reconstruction was subsequently
accomplished using the buried contra-lateral hemi-abdominal flap.
During harvest of the bailout flap we encountered large diameter
superficial inferior epigastric vessels and extremely small calibre
perforators from the deep system. We therefore decided to raise this
flap on the superficial system. The vessels were anastomosed
end-to-end to the original flap’s preserved deep inferior
epigastric vessels in the chest.
patient’s recovery after the second procedure was uneventful, and
she was discharged on postoperative day #6. A seroma in the
medial upper quadrant of the abdomen did develop, and it was
aspirated on the 14th
postoperative day. Follow up at 4 months showed good symmetry of the
reconstructed breast and satisfactory appearance (Fig. 4).
2 was a 63-year-old active smoker who had a right
lumpectomy for stage 2 lobular multicentric breast cancer in January
2005. She subsequently underwent adjuvant radiation and chemotherapy.
In January 2007 the patient was referred to us for possible bilateral
mastectomy and breast reconstruction. However, she was not willing to
undergo a prophylactic mastectomy of the uninvolved left breast.
After discussion she agreed to have the unused hemi-abdominal flap
buried for potential future reconstruction. As the patient had ample
abdominal tissue, only the right DIEP hemi-abdominal flap was used
for the reconstruction of the right breast. The internal mammary
vessels in the 4th
intercostal space were used as recipient vessels for the flap. The
left hemi-abdominal flap was de-epithelialized and advanced centrally
to maintain symmetry. The abdominal closure was achieved with the
abdominoplasty flap thinned over the underlying buried tissue to
decrease the appearance of a bulge. Her breast reconstruction
healed uneventfully; however, the abdominal wound was complicated by
skin necrosis in the midline below the umbilicus, where aggressive
thinning had been undertaken. The 7x12 cm necrosis was excised
one month after the reconstruction, and the defect was covered with
a split thickness skin graft which healed well.
experience with free abdominal flaps began in 1992 and is so far
based on more than 500 abdominal free tissue transfers. These include
TRAM flaps, DIEP flaps and SIEA flaps. Our data shows that our total
flap failure rate is 3%, comparable to published data (6, 11, 12).
the patients described in our article the “spare hemi-abdominal
flap” was buried under the abdominoplasty closure, on the basis
that it might be possible to use it in case of development of
a contra-lateral breast cancer requiring reconstruction, or as
a bailout flap in the event of flap failure. This approach saves
a patient from another remote donor site defect. We feel that
the original flap loss in patient 1 was secondary to microcirculation
failure within the flap. This phenomenon has already been described
in 1987 using an experimental rodent model (13). We think that in
this case the prolonged vasospasm inside the flap most likely led to
the subsequent thrombosis of small vessels, despite patency of the
main pedicle for three days. The continued patency of the main
vessels may have been a result of persistent circulation through
open A-V shunts in the pedicle of the DIEP flap. The bailout flap
used in this patient was based on the superficial system, because the
significantly small size of the perforators from the deep epigastric
vessels would probably have forced us to harvest a “mini TRAM”
flap, with its associated higher abdominal wall morbidity.
the case of Patient 2, the flap healed uneventfully, and therefore
the “spare” hemi-abdominal flap did not have to be used
immediately. However, if required in the future, it is available for
reconstruction. Central advancement of the flap under the abdominal
closure was performed, to prevent an asymmetric bulge in the lateral
abdominal wall. The necrosis of the central abdominal flap was
a complication most likely caused by excessive tension on
closure, aggressive flap thinning, and her history of smoking.
Whether the extra tissue buried under the central portion of the flap
exacerbated the situation is certainly a possibility; however,
this is a known complication even in standard abdominoplasty
closures, especially in smokers.
believe the following clinical scenarios may benefit from having the
hemi-abdominal flap preserved:
Patients with high risk of contra-lateral breast
cancer who do not wish to have simultaneous prophylactic
contra-lateral mastectomy and reconstruction. This
“spare flap” can avoid added donor site
deformity if future reconstruction of the opposite breast is
If there is a concern in the operating room
about the reliability of the original unilateral breast
reconstruction or the patient is at high risk for flap failure in the
Banking this “spare” hemi-abdominal flap might
also be useful for less experienced microsurgeons to have a possible
bailout in case of problems.
technique has some obvious limitations and drawbacks. It is suitable
only in patients who have a relative abundance of abdominal
tissue compared to the amount of tissue required for breast
reconstruction, and it is ideal only in patients who undergo skin
sparing/subcutaneous mastectomies. One has to de-epithelialize the
tissue prior to burying, and therefore this limits the clinical
indications in which it is used for future breast reconstructions. It
would ideally be suited only in mastectomies that retain all or most
of the skin envelope (subcutaneous or skin sparing mastectomies). If
one needed to use the flap in a situation where skin coverage
was also required (simple mastectomy), a full or split thickness
skin graft to the de-epithelialized flap would be an option, although
this would negatively impact the aesthetic result. Another option
would be to harvest the “spare” flap with the overlying abdominal
skin, although abdominal closure may become difficult requiring
a skin graft at the donor site. Probably, where applicable, the
best result would be obtained by staged expansion of the chest wall
skin and subsequent use of the “spare” hemi-abdominal flap for
volume fill. Thus the benefit of using autologous tissue instead
of a permanent implant is maintained.
possible donor site asymmetry and bulge is another potential
disadvantage of this technique which the patient must be willing to
accept. This asymmetry can be reduced by advancing the flap
centrally, thus balancing the appearance. One must be cognisant of
the potential necrosis of the abdominal flap if aggressive thinning
is undertaken to decrease the appearance of the bulge, which may
require surgical debridement and possible skin grafting with
resultant donor site morbidity and poor aesthetic outcome.
Liposuction of the area can always be performed if this asymmetry or
bulge is of great concern to the patient.
present a useful concept, based on our early experience with two
cases, of burying the unused hemi-abdominal flap in unilateral breast
reconstructions that can be accomplished by using solely the
contra-lateral abdominal flap. The buried tissue can serve as
a “spare” flap (DIEP, TRAM or SIEA) in high risk patients
who may need future contra-lateral breast reconstructions, or as
a bailout flap in the case of original flap loss. The use of the
buried flap is best suited for patients undergoing skin
sparing/subcutaneous mastectomies, and patients must be willing to
accept a certain degree of abdominal wall asymmetry and/or
flap – Deep Inferior Epigastric artery Perforator flap
the authors listed above contributed to the writing of the manuscript
or assisted in the surgeries. The idea of the surgery comes from the
senior author Jiri Vesely, and the surgeries were performed by him.
This work was supported by the grant IGA-MZCR Nr. 8368-5.
of Plastic and Aesthetic Surgery
1. Alderman AK., Kuhn LE., Lowery JC., Wilkins EGJ. Does patient satisfaction with breast reconstruction change over time? Two-year results of the Michigan Breast Reconstruction Outcomes Study. Am. Coll. Surg., 204:7, 2007.
2. Allen RJ., Treece P. Deep inferior epigastric perforator flap for breast reconstruction. Ann. Plast. Surg, 32:32, 1994.
3. Blondeel PN. One hundred free DIEP flap for breast reconstructions: a personal experience. Br. J. Plast. Surg., 52:104, 1999.
4. Dao TN., Verheyden CN. TRAM flaps: a reconstructive option after bilateral nipple-sparing total mastectomy. Plast. Reconstr. Surg., 116:986, 2005.
5. Futter CM., Webster MH., Hagen S. et al. A retrospective comparison of abdominis muscle strength following breast reconstruction with a free TRAM or DIEP flap. Br. J. Plast. Surg., 53:578, 2000.
6. Gill PS., Hunt JP., Guerra AB. et al. A 10-year retrospective review of 758 DIEP flaps for breast reconstruction. Plast. Reconstr. Surg., 113:1153, 2004
7. Guerra AB., Metzinger SE., Bidros RS., et al. Bilateral breast reconstruction with the deep inferior epigastric perforator (DIEP) flap: an experience with 280 flaps. Ann. Plast. Surg., 52:246, 2004.
8. Granzow JW., Levine JL., Chiu ES. et al. Breast reconstruction with the deep inferior epigastric perforator flap: History and an update on current technique. JPRAS, 59:571, 2006.
9. Greenway RM., Schlossberg L., Dooley WC. Fifteen-year series of skin-sparing mastectomy for stage 0 to 2 breast cancer. Am. J. Surg, 190:918, 2005.
10. Lindsey JT. Integrating the DIEP and muscle-sparing (MS-2) free TRAM techniques optimizes surgical outcomes: presentation of an algorithm for microsurgical breast reconstruction based on perforator anatomy. Plast. Reconstr. Surg., 119:18, 2007.
11. Nahabedian MY., Momen B., Galdino G. et al. Breast reconstruction with the free TRAM or DIEP flap: patient selection, choice of flap, and outcome. Plast. Reconstr. Surg., 110:466, 2002.
12. Nahabedian MY., Tsangaris T., Momen B. Breast reconstruction with the DIEP flap or the muscle sparing (MS-2) free TRAM flap: is there a difference? Plast. Reconstr .Surg., 115:436, 2005.
13. Vesely J., Samohyl J., Barinka L. et al. Gewebeschock bei freien Lappen im Experiment an der Ratte. Handchir. Mikrochir. Plast. Chir., 19:269, 1987.