Refinements in free flap breast reconstruction: the free bilateral deep inferior epigastric perforator flap anastomosed to the internal mammary artery.

Besides the enormous advantages of reconstructing the amputated breast by means of a conventional TRAM flap, the main disadvantage remains the elevation of small (free TRAM) or larger (pedicled TRAM) parts of the rectus abdominis muscle. In order to overcome this disadvantage, the free Deep Inferior Epigastric Perforator (DIEP) skin flap has recently been used for breast mound reconstruction with excellent clinical results. After achieving favorable results with eight unilateral DIEP-flaps, we were challenged by an abdomen with a midline laparotomy scar. By dissecting a bilateral DIEP flap and making adjacent anastomoses to the internal mammary artery we were able to achieve sufficient flap mobility for easy free flap positioning and breast shaping. Intraoperative segmental nerve stimulation, postoperative functional abdominal wall tests and CT-scan examination showed normal abdominal muscle activity. On the basis of a case report, the technical considerations and advantages of anastomosing the bipedicled DIEP flap to the internal mammary artery are discussed.