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Correspondence to A. K. Agarwal. Address: Department of Plastic Surgery, Queen Victoria Hospital, Holtye Road, East Grinstead, West Sussex RH19 3DZ, UK
Affiliations
Department of Plastic Surgery, University Hospital of North Durham, Durham, UK
A two-stage procedure using bilateral free DIEP flaps to correct excessive bilateral breast reduction is described. The reconstructive challenge was to achieve satisfactory breast projection on a large torso without recourse to prosthetic implants or extensive back scars. The literature on the use of TRAM and latissimus dorsi flaps in subtotal breast reconstruction for various other breast deformities is reviewed. We have not found a similar case to ours in the literature.
However, Wise-pattern ‘anchor-scar’ techniques have the potential to produce flat breasts due to insufficient breast-volume preservation and/or insufficient tightening of the skin envelope. This is particularly so in surgery for massive hypertrophy using the free-nipple-graft technique, where central bulk carried by an inferior pedicle is lacking. We describe the use of de-epithelialised free DIEP flaps for augmentation following excessive bilateral breast reduction. The patient was reluctant to have breast implants or back scars secondary to latissimus dorsi transfer. This surgical problem was effectively solved by bilateral free DIEP flap ‘breast augmentation’. To the best of our knowledge, this is the first such use of these flaps reported in the English literature.
1. Case report
A 47-year-old retired Caucasian nurse was referred by her family physician 4 years after excessive bilateral reduction mammaplasty with free nipple grafting performed in another area. Her main complaint was a lack of breast projection, necessitating the use of padded brassieres.
Examination confirmed very flat breasts with a male chest appearance. This was a significant cause of psychological upset and a poor body image. Scarring was consistent with a standard Wise-pattern type breast reduction, and both free nipple grafts had taken well (Fig. 1) .
Figure 1(A) Anterior and (B) oblique preoperative views 4 years after bilateral breast reduction.
The reconstructive options were explained, and the patient chose to have a free autologous tissue transfer from her ample abdominal panniculus. Reconstruction using two-stage bilateral free DIEP flaps was performed successfully, with the vascular anastomoses being made end-to-end to the thoracodorsal vessels in each axilla. In the first stage, monitoring skin paddles were inset as crescents immediately above the inframammary folds, with the remainder of the flap being de-epithelialised and used to augment the breast remnant in the pre-pectoral plane. The patient made an uneventful recovery, and both flaps survived completely, without any complications. The early postoperative results are shown in Figure 2. The second stage was performed 11 months later to ‘tidy-up’ and inset the flaps fully and contour the axillary folds. The patient is now satisfied with her body image and, at her most recent follow-up 15 months following the DIEP flaps, there has been no loss of breast volume or projection (Fig. 3) .
Figure 2(A) Anterior and (B) oblique early postoperative views after breast augmentation using bilateral free DIEP flaps.
Breast reconstruction with autologous tissue alone has many attractions for patients and plastic surgeons alike. A satisfactory breast mound can sometimes be created without an implant by using an ‘extended’ pedicled latissimus dorsi flap,
Heitland A, Allen R, Pallua N. Recipient implant failure after aesthetic breast augmentation: management of a difficult problem with perforator flaps (DIEP/GAP flaps). Presented at the 13th Annual Meeting of the European Association of Plastic Surgeons (EURAPS), Crete, May 2002.
We have not found a reported use of DIEP flaps for reversal of excessive breast reduction.
In this case, the aim of bilateral near-total breast reconstruction (without the need for nipple-areola reconstruction) was achieved, respecting the patient's wishes, and use of DIEP flaps minimised abdominal donor-site morbidity.
Acknowledgements
We thank Dr R (Bob) Allen, MD for his advice on the management of this case.
References
Davis G.M
Ringler S.L
Short K
Sherrick D
Bengtson B.P
Reduction mammaplasty: long-term efficacy, morbidity, and patient satisfaction.
Heitland A, Allen R, Pallua N. Recipient implant failure after aesthetic breast augmentation: management of a difficult problem with perforator flaps (DIEP/GAP flaps). Presented at the 13th Annual Meeting of the European Association of Plastic Surgeons (EURAPS), Crete, May 2002.
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