Research Article| Volume 60, ISSUE 8, P904-912, August 2007

Double-pedicle abdominal perforator free flaps for unilateral breast reconstruction: new horizons in microsurgical tissue transfer to the breast

Published:April 13, 2007DOI:


      The DIEAP (deep inferior epigastric artery perforator) flap is a suitable option for breast reconstruction resulting in excellent aesthetic outcome, and minimal donor site morbidity. Contraindications for use of the DIEAP flap may include previous abdominal liposuction and/or surgery, or lack of abdominal tissue. The purpose of this paper is to describe options of using abdominal perforator flaps, based on double-pedicle techniques, despite these contraindications.
      A retrospective evaluation was carried out on a series of 16 patients who required abdominal double-pedicle free perforator flaps for unilateral breast reconstruction since June 2002. The indications were multiple abdominal scars, previous abdominal liposuction and thin patients in five, three and eight cases, respectively. Preoperative mapping of the vascular network was done using Duplex and/or multi-detector CT scan imaging. Clinical evaluation of medical charts was done regarding patients' characteristics, surgical techniques, ischaemia/total operative time and complications. A clinical evaluation was done on all patients with average follow up of 15 months. Fat necrosis was investigated clinically and by mammogram examination.
      Different microsurgical techniques were performed to provide enough blood supply to the requested flaps: Perforator (P) to contralateral Deep Inferior Epigastric (DIE) anastomosis (P/DIEAP), in two patients; bilateral DIE vessels (DIEAP/DIEAP) in seven patients; and DIE with SIE (superficial inferior epigastric) vessels in seven patients (DIEAP/SIEA). One pedicle was always anastomosed to the internal mammary vessels. The second pedicle was anastomosed end-to-end to a side branch of the DIE or end-to-side with the DIE pedicle in 13 cases. The thoracodorsal vessels were used as recipient vessels for the second pedicle in three cases. Average operative time was 6 h 30 min (range 5 h 30 min–8 h). All 16 flaps survived and fat necrosis occurred in one case.
      The harvesting of perforator free flaps may be contraindicated in some patients, however they are still a feasible option as long as the vessels to the skin are present. Preoperative planning combined with high expertise in microsurgical techniques are the key points in the high success rate in these difficult cases.


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      • Double-pedicle abdominal perforator free flaps for unilateral breast reconstruction: new horizons in microsurgical tissue transfer to the breast
        Journal of Plastic, Reconstructive & Aesthetic SurgeryVol. 60Issue 8
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          The authors are to be commended for sharing their experience and excellent results using perforator flaps for breast reconstruction. They expand on an idea that has been previously reported – successfully using abdominal tissue as donor site for perforator flaps even though it may have been injured due to prior surgical scars and/or liposuction.1,2 Furthermore, they push the envelope by performing two microsurgical procedures using this previously operated donor site to reconstruct one breast. Alternative donor site tissue or reconstructive technique is usually selected by microsurgeons when abdominal tissue is inadequate or potentially damaged.  
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