Management of infraumbilical vertical scars in DIEP-flaps by crossover anastomosis

Schoeller, Thomas; Wechselberger, Gottfried; Roger, Judith; Hussl, Heribert; Huemer, Georg M.

doi:10.1016/j.bjps.2006.11.008

« Previous Next »Journal of Plastic, Reconstructive & Aesthetic Surgery
Volume 60, Issue 5 , Pages 524-528, May 2007

Management of infraumbilical vertical scars in DIEP-flaps by crossover anastomosis

Thomas Schoeller
- Clinical Department of Plastic and Reconstructive Surgery, Innsbruck Medical University, Anichstrasse 35, 6020 Innsbruck, Austria
Gottfried Wechselberger
- Clinical Department of Plastic and Reconstructive Surgery, Innsbruck Medical University, Anichstrasse 35, 6020 Innsbruck, Austria
Judith Roger
- Clinical Department of Plastic and Reconstructive Surgery, Innsbruck Medical University, Anichstrasse 35, 6020 Innsbruck, Austria
Heribert Hussl
- Clinical Department of Plastic and Reconstructive Surgery, Innsbruck Medical University, Anichstrasse 35, 6020 Innsbruck, Austria
Georg M. Huemer
- Department of Plastic Surgery, Sisters of Mercy Hospital, Seilerstätte 4, 4020 Linz, Austria
- maz – Mikrochirurgisches Ausbildungs- und Forschungszentrum, Garnisonsstrasse 21, 4020 Linz, Austria
- Corresponding author. maz – Mikrochirurgisches, Ausbildungs- und Forschungszentrum, Garnisonsstrasse 21, 4020 Linz, Austria. Tel.: +43 699 10878705; fax: +43 732 77032513.

Received 29 March 2006; accepted 4 November 2006. published online 22 January 2007.

Summary

The deep inferior epigastric perforator (DIEP)-flap continues to be the standard treatment in microsurgical breast reconstruction. Reasons for the popularity of the DIEP-flap include the availability of a large amount of tissue for the reconstruction of large breasts, a reliable vascular anatomy and an aesthetically pleasing donor site scar. However, the DIEP-flap is not considered the optimal choice as the donor tissue in all patients. Previous abdominal surgeries with resulting scars may threaten the success of a free DIEP-flap due to compromised vascularity within the flap. We elaborated a technique to increase the safety of breast reconstruction with the DIEP-flap in the presence of an infraumbilical vertical scar.

After raising the DIEP-flap in a traditional manner on one side with harvesting of a considerate length of the inferior epigastric vessels, a segment of the superior epigastric vessels is left attached to the main pedicle. This stump of the superior epigastric vessels is now anastomosed under the microscope to a paraumbilical perforator on the contralateral side of the flap for in-flap microvascular augmentation.

The above-mentioned technique was applied in five patients who presented with an infraumbilical vertical scar and were reconstructed with a DIEP-flap because of breast cancer. In three of the five patients there was an additional risk factor present such as smoking or diabetes mellitus. In all five patients no major complication due to marginal perfusion of the contralateral side of the flap was encountered. In two patients there was minor breakdown of fatty tissue that was managed conservatively in both cases.

In-flap microvascular augmentation of DIEP-flaps is a valuable tool for the plastic surgeon in microvascular breast reconstruction. It permits usage of the lower abdominal tissue even if perfusion is compromised due to midline scarring. We recommend this technique as a safe alternative in patients seeking autologous breast reconstruction in the presence of a midline abdominal scar.

Keywords: Breast reconstruction, DIEP-flap, Microsurgery, Vertical scar