A strategic approach for DIEP flap breast reconstruction in patients with a vertical midline abdominal scar

BACKGROUND: Deep inferior epigastric perforator (DIEP) flaps have become broadly accepted for autologous breast reconstruction. Our aim was to analyze outcomes and describe technical strategies to improve survival when harvesting the entire DIEP flap with a midline scar. METHODS: We retrospectively reviewed charts from March of 2000 to November of 2007; 186 DIEP flaps in 183 patients were used for breast reconstruction, including 18 flaps (9.68%) in 17 patients with previous lower midline abdomen scars. The patients were classified into 3 groups. Group 1: hemi-DIEP flaps (n = 5);. group 2: DIEP flaps that included tissue crossing the midline (n = 10); and group 3: entire-DIEP flaps (with zone IV) (n = 3). RESULTS: Reexploration for venous congestion and partial flap loss were encountered in 1 patient in group 1. Average flap-used ratio was 68.75 ± 8.95% in group 2. Three flaps developed partial loss and underwent subsequent debridement. In group 3, entire DIEP flaps were designed with higher, bilateral superficial inferior epigastric venous drainages and intraflap pedicle-to-pedicle anastomosis. The first 2 cases underwent partial flap loss and debridement. The third case of bipedicle anastomosis achieved complete flap survival. CONCLUSIONS: The hemi-DIEP flap is a safer method for the patient with a lower abdominal midline scar but limits the reconstructive volume. Carefully evaluating the perfusion across midline scar intraoperatively is crucial for deciding how much contralateral tissue should be discarded. Double pedicles anastomosis is an assurance for using entire DIEP flap with lower midline scar.