What are the recommended flaps for breast reconstruction after an inframammary incision?

Recommended Flaps for Breast Reconstruction After Inframammary Incision

The Deep Inferior Epigastric Perforator (DIEP) flap is the preferred autologous option for breast reconstruction, as it provides optimal tissue volume from the lower abdomen while preserving the rectus abdominis muscle, resulting in superior donor site outcomes compared to muscle-sacrificing alternatives. 1

Primary Flap Options

DIEP Flap (First-Line Autologous Choice)

• Preserves the entire rectus abdominis muscle, eliminating the donor site morbidity associated with traditional TRAM flaps while providing equivalent reconstructive outcomes 1
• Results in less fat necrosis, reduced hernia risk, and preserved abdominal wall function compared to transverse rectus abdominis muscle (TRAM) flaps 1
• Uses perforator branches from the deep inferior epigastric artery, which has a consistent origin from the external iliac artery 2
• The ideal perforator should be large caliber, medially located within the flap, with an extended vascular territory beyond the midline to provide optimal perfusion 1, 2

Latissimus Dorsi Myocutaneous Flap (Alternative Option)

• Utilizes the latissimus dorsi muscle from the back with a reliable blood supply from the thoracodorsal artery 3
• Can replace relatively large volumes of breast tissue and is particularly useful when radiation therapy is anticipated, as autologous tissue tolerates radiation better than implants 1, 3
• May be used alone or combined with implants to achieve better symmetry and volume 3
• Has acceptable donor-site morbidity and improves quality of life for mastectomy patients 3

Free TRAM Flap (Historical Alternative)

• Uses transverse rectus abdominis muscle with overlying skin and fat from the lower abdomen 1
• Now largely superseded by DIEP flaps due to increased donor site morbidity from muscle sacrifice 1

Preoperative Planning Requirements

Imaging for DIEP Flaps

• CT angiography (CTA) of the abdomen and pelvis with IV contrast is the gold standard for preoperative planning, with 96% sensitivity for all perforators and 100% sensitivity for perforators >1 mm 1
• MR angiography (MRA) of the abdomen and pelvis without and with IV contrast is a reasonable alternative, particularly when avoiding radiation exposure 1
• Preoperative imaging demonstrates decreased operative time, reduced flap loss rate, decreased hernia rate, reduced intraoperative blood loss, and shorter hospital stays compared to handheld Doppler alone 1

Perforator Selection Criteria

• Perforators are ranked based on size (largest caliber preferred), location (medial preferred), and intramuscular course (shorter course preferred) 1, 2
• The perforator anatomy is variable and may differ between right and left hemi-abdomen in the same patient, classified as single trunk (type 1), bifurcating (type 2), or trifurcating (type 3) 1, 2

Clinical Outcomes and Success Rates

• DIEP flaps have been successfully performed in over 1,095 cases with reliable tissue transfer and minimal donor site morbidity 4
• The technique allows transfer of the same abdominal tissue as TRAM flaps without sacrifice of rectus muscle or fascia 4, 5
• Total flap survival is achievable even in challenging cases, including patients with previous liposuction of donor sites, when preoperative color Duplex imaging is obtained 6

Important Caveats

• Smoking and obesity are relative contraindications due to increased risk of wound healing complications and partial or complete flap failure 3
• Immediate reconstruction can be performed at the time of mastectomy, or delayed reconstruction can occur any time after mastectomy 3
• When postmastectomy radiation therapy is anticipated, autologous tissue reconstruction (DIEP or latissimus dorsi) is preferred over implant-based reconstruction 1, 3
• Breast reconstruction does not make detection of local recurrence more difficult 1