The Low DIEP Flap for Breast Reconstruction.

Supplemental Digital Content is available in the text.

The goal of the low deep inferior epigastric perforator (DIEP) flap design is to place the donor scar as low as possible in the lowermost part of the abdomen.[1] The low DIEP flap was indicated in cases where the breasts were small to moderately sized and reliable perforators were found more than 4 cm below the umbilicus in computed tomography angiogram. Therefore, the low DIEP flap can be applied to limited number of patients who have dominant or second dominant perforator way below the umbilicus. If nondominant perforator were selected, there will be a higher chance of venous congestion.[2] Meticulous planning with computed tomography angiography is crucial when deciding between the low DIEP flap and the conventional DIEP flap. Since the volume of the low DIEP flap tends to be smaller than the conventional DIEP flap, patients with too large sized breasts are generally not good candidates for the low DIEP flap. The low DIEP flap might not be the best choice in delayed reconstruction, because lower part of the flap skin has pubic hair.

OPERATIVE PROCEDURES

The lower border of the flap was on the pubic rim and the upper border was usually located 4–6 cm below the umbilicus. Using Doppler, perforator location was confirmed on the patient’s skin. If the perforator was not in the flap territory, the flap design should be adjusted higher. See video, Supplemental Digital Content 1, which shows the design of the low DIEP flap and incision and flap elevation just before perforator dissection. This video is available in the Related Videos section of the Full-Text article on PRSGlobalOpen.com, http://links.lww.com/PRSGO/A645. Beveling upward was helpful for recruiting more volume and protecting the perforator close to the incision line. The rest of the flap elevation process was not different from the conventional DIEP flap (see video, Supplemental Digital Content 2, which shows the process of perforator dissection from the muscle and main pedicle separation. This video is available in the Related Videos section of the Full-Text article on PRSGlobalOpen.com, http://links.lww.com/PRSGO/A646). Flap was trimmed and placed vertically to maximize ptotic naturalness. Fixation was done along the upper and medial borders of the flap (see video, Supplemental Digital Content 3, which shows flap trimming, inset and fixation. This video is available in the Related Videos section of the Full-Text article on PRSGlobalOpen.com, http://links.lww.com/PRSGO/A647).

Design and incision. See video, Supplemental Digital Content 1, which shows the design of the low DIEP flap and incision and flap elevation just before perforator dissection. This video is available in the Related Videos section of the Full-Text article on PRSGlobalOpen.com, http://links.lww.com/PRSGO/A645.

Perforator dissection. See video, Supplemental Digital Content 2, which shows the process of perforator dissection from the muscle and main pedicle separation. This video is available in the Related Videos section of the Full-Text article on PRSGlobalOpen.com, http://links.lww.com/PRSGO/A646.

Flap trimming, inset and fixation. See video, Supplemental Digital Content 3, which shows flap trimming, inset and fixation. This video is available in the Related Videos section of the Full-Text article on PRSGlobalOpen.com, http://links.lww.com/PRSGO/A647.

Donor closure could be tried without umbilical detachment, when the distance from the umbilicus to the upper flap margin was longer than 5 cm. If there was too much tension below the umbilicus and umbilical shape was deformed, the umbilicus was detached from the abdominal wall and then dragged down and fixed to a new location (see video, Supplemental Digital Content 4, which shows the direct donor closure with umbilical relocation. This video is available in the Related Videos section of the Full-Text article on PRSGlobalOpen.com, http://links.lww.com/PRSGO/A648). If the distance from the umbilicus to the upper flap margin was shorter than 5 cm, a periumbilical incision and neo-umbilicus creation would be better. The abdominal scar left by the low DIEP flap was close to the pubic rim and could be concealed by underwear.

Donor closure with umbilical relocation. See video, Supplemental Digital Content 4, which shows the direct donor closure with umbilical relocation. This video is available in the Related Videos section of the Full-Text article on PRSGlobalOpen.com, http://links.lww.com/PRSGO/A648.

During the period from May 2014 to April 2016, 227 consecutive cases underwent breast reconstruction with DIEP flap, Of these, 57 underwent low DIEP flap surgery. All breast reconstruction was successful except for 1 case of flap failure. The low DIEP flap leaves a much more favorably located donor scar and umbilicus shape (Fig. 1). When compared with conventional DIEP flap group, the low DIEP flap group showed higher incidence of venous congestions. Most of the venous congestion occurred in our early series when the perforator selection was not strictly controlled, and they were all salvaged with venous augmentation using the superficial inferior epigastric vein. The low DIEP flap group and the conventional DIEP flap group did not differ in terms of fat necrosis and donor-site complication rates.

Fig. 1.

(a) Preoperative photograph of a patient with left breast cancer (b) Six months postoperative photograph of breast reconstruction with the low DIEP flap