The Deep Inferior Epigastric Perforator (DIEP) flap is the preferred method of autogenous
breast reconstruction as it provides an ideal replacement for the absent breast tissue
with minimal donor site morbidity and improved abdominal contour. When a single hemiabdomen
is inadequate for unilateral reconstruction the volume and projection can be augmented
with an implant, or the experienced microsurgeon may offer stacked DIEP flaps.[1] An additional consideration would be the use of both hemiabdominal flaps in addition
to an implant. This hybrid combination could maximize the autogenous contribution
to the reconstruction allowing the use of a smaller implant. Additionally, total implant
coverage with stacked DIEP flaps could help prevent rippling, improve projection,
and lessen implant palpability. We describe two cases of hybrid reconstruction combining
stacked DIEP flaps with immediate silicone implantation to improve reconstructive
outcomes.
Cases
Ms. DD is a 60-year-old woman with a history of left breast cancer who underwent left
mastectomy (875 g) without immediate reconstruction and right-sided reduction mammoplasty.
She then received adjuvant radiotherapy to the left chest and subsequently underwent
delayed hybrid stacked DIEP flap plus implant breast reconstruction. A 120cc moderate
profile silicone implant was placed atop the pectoralis muscle and secured to the
chest wall with acellular dermal matrix (ADM). The left hemiabdominal flap (490 g)
was deepithelialized and placed atop the superior portion of the implant filling the
upper pole of the breast. The right flap (505 g) served as the superficial flap covering
the lower portion of the implant and partly overlapping the deep flap for improved
projection. An antegrade/retrograde perfusion pattern was created and both flaps were
well-perfused providing thick and complete autogenous implant coverage.
Ms. AA is a 62-year-old woman with a history of left breast cancer who underwent left
mastectomy, immediate implant reconstruction, and right breast augmentation at an
outside facility. After multiple revisions she remained unsatisfied with her result.
She presented with breast asymmetry and thinning of the breast skin with obvious rippling
([Fig. 1]). A stacked DIEP flap plus implant hybrid was used to reconstruct her breast. A
500cc moderate profile implant was removed and a 158cc moderate-plus implant was placed
atop the pectoralis muscle and secured to the chest wall with ADM. The left hemiabdominal
flap (200 g) was deepithelialized and inset dermis side up to reconstruct the lower
pole and cover the inferior aspect of the implant. The right hemiabdominal flap (205
g) was also deepithelialized and inset dermis side up to reconstruct the upper pole
of the breast and cover the superior aspect of the implant. A branch chain perfusion
pattern was successfully created and the flaps were sutured to one another as they
lay side by side providing total implant coverage; eliminating the upper pole rippling
([Fig. 2]).
Fig. 1 Preoperatively, the upper pole of patient AA's reconstructed left breast demonstrates
visible rippling secondary to the thin mastectomy flap skin and lack of soft tissue
coverage.
Fig. 2 Immediate postoperative result of stacked DIEP flap plus implant hybrid breast reconstruction.
Note the improvement in the left upper pole eliminating the visible rippling.
Discussion
A single DIEP flap often provides sufficient tissue for unilateral reconstruction,
but may be inadequate to reconstruct larger breasts in patients with leaner abdomens.[1]
[2]
[3]
[4] In such cases, as the two presented above, several options may be considered including
primary implant augmentation of a single DIEP flap.[2]
[3] Figus et al. describes 14 such cases of subpectoral implants placed primarily at
the time of DIEP reconstruction with a reported average of 20% or 1:5 implant to flap
weight ratio. The authors suggest that the implant primarily contributes to breast
volume, while shape and projection depends mostly on the abdominal tissue.[2] The procedure is less technically demanding than stacked flaps, but there is an
associated risk of implant-related complications such as infection or malpositioning
which could lead to vascular compromise if the implant impinges on the flap pedicle.
Another option when a single DIEP flap fails to provide sufficient tissue for unilateral
reconstruction, includes the sequential linkage and stacked inset of two individual
DIEP flaps as described by DellaCroce et al. While a lengthier and more technically
difficult operation, stacked DIEP reconstruction has many benefits. Perhaps it's greatest
benefit is geometric versatility. Tailoring of inset patterns can achieve the best
possible breast shape and symmetry for the patient.[1]
[4] In addition it takes advantage of low donor site morbidity, often improves abdominal
contour, and has been demonstrated to have excellent, reproducible aesthetic outcomes
and patient satisfaction.
Recently, we have had success combining these two approaches using a stacked DIEP
plus implant hybrid reconstruction. In each case we felt the patient would benefit
from the additional volume and projection offered by a well-placed silicone implant
but we also desired thick and complete autogenous implant coverage to prevent visible
rippling and lessen implant palpability. We chose to the place the implant in the
pre-pectoral position just adjacent to the lateral border of the internal mammary
access site to maximize projection. We carefully secured the position of the implant
with ADM paying particular attention to suture the medial border of the ADM to the
perichondrium of the 4th cartilaginous rib defect to prevent medial migration. We
accepted the cost associated with the ADM because of the security of implant positioning
that it afforded. The hybrid construct takes advantage of the stacked DIEP's inset
pattern versatility including arrangements such as the side by side inset used in
AA's case versus a partially overlapping inset as in DD's case. These inset patterns
were chosen to ensure complete implant coverage and improve projection where necessary
for each patient, all while maintaining flexibility in vascular construct arrangement.
Conclusion
Stacked DIEP flap and implant reconstruction is a reasonable option for cases when
adequate volume and projection cannot be obtained with stacked DIEP reconstruction
alone. This approach combines the implant's volume and projection augmentation with
the stacked-DIEP's inset pattern versatility to ensure total implant coverage while
simultaneously tailoring breast shape and projection for optimal, individualized aesthetic
outcomes.
