Aesthetic Breast Reconstruction With De-epidermized Deep Inferior Epigastric Artery Perforator Flap and Thoracoabdominal Advancement Flap

Abstract

Background:

Most regard the deep inferior epigastric artery perforator (DIEP) flap as the gold standard in autologous breast reconstruction, with good breast aesthetics achieved and low donor site morbidity. Mojallal et al introduced a new surgical protocol to enhance results for both the breast and abdomen further. This study presented the first clinical series of patients benefitting from breast reconstruction based on a combination of a DIEP flap and a thoracoabdominal advancement flap (TAAF).

Methods:

A retrospective study was conducted at our institution from January 2013 to October 2020. We included all 100 consecutive patients in whom the technique was used. Patients’ characteristics, types of surgical procedures, and outcomes were recorded. Patient satisfaction and quality of life were measured with BREAST-Q 2.0 reconstructive modules.

Results:

A total of 101 DIEP flaps and 100 TAAFs were included. The mean follow-up was 26.9 months. In all cases, the DIEP skin paddle could be removed, and the abdominal scar was concealed under the patient’s undergarments. No TAAF necrosis or major abdominal complications were recorded. Four DIEP flap failures were successfully treated with implants, lipofilling, or muscle-sparing latissimus dorsi flaps while preserving the benefit of the TAAF. Breast and abdominal aesthetics were satisfying, with high BREAST-Q scores.

Conclusions:

The TAAF combined with the DIEP flap is a reliable technique for delayed unilateral breast reconstruction. Excellent aesthetic results and high patient satisfaction can be achieved without compromising safety.

Takeaways

Question: Is the deep inferior epigastric artery perforator (DIEP)–thoracoabdominal advancement flap (TAAF) technique safe and effective for delayed breast reconstruction?

Findings: A retrospective review of 100 cases showed excellent outcomes using the combined DIEP–TAAF technique. The method achieved high aesthetic satisfaction and no major complications, with a mean follow-up of 26.9 months.

Meaning: The DIEP–TAAF technique offers a reliable, safe, and aesthetically superior approach to delayed unilateral breast reconstruction, enhancing both breast and donor site outcomes.

INTRODUCTION

In the past decades, the deep inferior epigastric perforator (DIEP) flap has progressively become the gold standard for autologous breast reconstruction, as the technique provides satisfactory aesthetic results with limited donor site morbidity.^1,2 Generally, the DIEP flap is used to restore both the volume and the skin of the breast. The thorax is thus interspersed with an abdominal skin patch, resulting in a color and texture mismatch.^3,4 Thoracic teguments may also have to be excised to adequately accommodate the new skin paddle, potentially creating a significant defect in the case of flap failure. These 2 pitfalls can be addressed with an independent reconstruction of the breast volume by the DIEP flap and the skin envelope with the adjacent teguments. A first option is to use skin expansion devices to recreate a skin envelope large enough to accommodate a de-epidermized DIEP flap. An additional procedure is required, and the expansion protocol delays microsurgical reconstruction by several weeks. Multiple complications can occur, especially in irradiated patients.^5,6

A novel approach was introduced in 2010 by Mojallal et al⁷ in which skin envelope and breast volume are reconstructed separately yet simultaneously by a thoracoabdominal advancement flap (TAAF) and a DIEP flap. The surgical protocol was also revised to enhance donor site aesthetics. We present our operative technique and results in a retrospective review of a 100-patient series.

PATIENTS AND METHODS

Patients and Study Design

This retrospective study was conducted in our plastic and reconstructive surgery department at Croix-Rousse Hospital, Lyon, from January 2013 to October 2020. All consecutive delayed autologous breast reconstructions with DIEP and TAAF performed by senior authors (A.M., F.B., and H.S.) were included. The study was designed and conducted according to the principles of the Declaration of Helsinki.⁸

Age, body mass index (BMI), pregnancy history, main comorbidities,⁹ and oncological treatment were recorded for each patient. Timing, type of procedures performed, complications, and follow-up were noted. Patient satisfaction and quality of life were assessed postoperatively with the breast and abdomen modules of the BREAST-Q 2.0 reconstruction questionnaire. Statistical analyses were conducted using IBM SPSS Statistics 29.0 (IBM SPSS, Inc., Chicago, IL).

Surgical Procedures

TAAF and DIEP Flap

The surgical protocol has already been reported⁷ and summarized in Supplemental Digital Content 1. (See figure, Supplemental Digital Content 1, which displays a diagrammatic representation of the 3 steps of the procedure, https://links.lww.com/PRSGO/E207.) Briefly, preoperative markings locate the desired position of the inframammary fold (IMF) and determine the amount of downward skin undermining required for the TAAF (Figs. 1A, B). (See Video 1 [online], which displays the preoperative markings.) A prepectoral pocket is dissected, and the TAAF is elevated above the thoracoabdominal fascia up to the inferior preoperative marking. A double row of concentric figure-of-8 sutures on both sides of a Scarpa fascia incision anchors the TAAF and defines the inferior and lateral mammary folds. The DIEP flap is procured from the opposite side of the reconstructed breast, and zone IV¹⁰ of the flap (usually discarded in standard procedures) is left on the abdomen. After microsurgical anastomosis to the internal mammary artery, the DIEP flap is shaped, and most of the skin paddle is de-epidermized.¹¹ A small portion of the flap skin is left intact for monitoring, preferably with a perforator marking to facilitate Doppler monitoring. Because the TAAF primarily defines the shape of the reconstructed breast, extensive remodeling of the DIEP flap is unnecessary. Only 2 internal fixation points, superior and lateral, are required. To achieve breast projection and elegant ptosis, a conical breast mound is effectively recreated using concentric advancement of the TAAF and radial incisions the Scarpa fascia. Rotating the flap 180 degrees positions the thicker midabdominal region at the inferior pole of the breast, enhancing the asymmetrical projection of the breast conus.¹² Some of the key aspects relative to the TAAF are detailed in Video 2. (See Video 2 [online], which displays TAAF key considerations.) The abdomen is closed, with the umbilicus positioned slightly higher than the final desired location to accommodate future descent during the second procedure. Costal cartilage excised during recipient site preparation is placed into a subcutaneous pocket above the groin fold.

Fig. 1.

Photographs of preoperative markings. A, Before the first intervention, note the skin imprints from the silicone external prosthesis, which helps soften the teguments. B, Preoperative markings of the first procedure: TAAF and contralateral DIEP flap; zone 4 is preserved and left in place on the patient’s abdomen. C, Second procedure markings: lipoabdominoplasty, contralateral mastopexy, DIEP burial, and bilateral breast lipofilling. D, Final result after a third surgery under local anesthesia for NAC reconstruction.

Video 1. This video shows DIEP-TAAF preoperative markings.

Download video file ^{(79.4MB, mp4)}

Video 2. This video shows TAAF key operative aspects.

Download video file ^{(86.5MB, mp4)}

Second-stage Surgery

A revision lipoabdominoplasty, without umbilical transposition, is performed to lower the abdominal scar, ensuring it is concealed within underwear while enhancing silhouette contouring. The reconstructed breast is then reshaped, the remaining DIEP skin paddle is trimmed (if used for nipple–areolar complex [NAC] reconstruction) or excised, and fat grafting is carried out. Contralateral mastopexy or reduction mastoplasty is performed using a posterosuperior glandular pedicle and a 3-scar technique¹³ (Figs. 1C, D). If percutaneous IMF redefinition is required, the hypodermis is lipoaspirated with a no. 5 short cannula. External fixation is then achieved with deep anchoring bites using Prolene 3.0 sutures, either interrupted or continuous, depending on the length of the revision needed. Stitches and IMF taping are left in place for 2 weeks (Fig. 2). In cases where a more pronounced revision is required, we add an internal, buried running suture using a looped polydioxanone suture 0. Fixation begins at the lateral aspect of the IMF through a small (approximately 1 cm) incision. The needle is then passed percutaneously at regular intervals along the IMF toward the medial aspect, with deep bites through the same entry and exit points, anchoring the dermis in the desired position. Upon reaching the medial aspect of the IMF, the suture is reversed back along the same path toward the lateral incision, allowing for controlled tightening of the IMF to achieve the intended tension. We then proceed with the external transient suture as described earlier.

Fig. 2.

Photograph of an IMF percutaneous revision.

Third and Fourth Stages of Surgery

Final refinements are made. The third procedure can be performed under local anesthesia as an outpatient if limited to NAC reconstruction.^14,15 For more extensive breast remodeling, NAC reconstruction is deferred to a fourth step to ensure optimal positioning.

RESULTS

A total of 100 patients, 101 DIEP flaps, and 100 TAAFs were included in the study. The mean delay between the final surgical stage and inclusion in the study was 50.8 ± 28 months. Three patients were excluded: 2 due to oncological recurrence and 1 due to a diagnosis of chronic myeloid leukemia following the first surgery, which precluded further reconstruction. Among the reconstructions, 3 homolateral TAAFs and DIEP flaps and 1 bilateral DIEP flap reconstruction (comprising a unilateral TAAF and a contralateral implant-to-DIEP flap conversion) were performed. Patient characteristics at the time of the first intervention are detailed in Table 1.

Table 1.

Clinical Demographics

Variable	Value
No.	100
Mean age at first surgery ± SD, y	50.41±7.78
Mean BMI ± SD, kg/m2	26.72±4.55
At least 1 comorbidity	44
Obesity (BMI > 30 kg/m2)	18
Diabetes mellitus	5
Smoking history	17
Hypertension	15
History of pregnancy Mean parity	91 2.16±1.17
Radiation therapy	76
Mean delay from last radiation therapy to first surgery, mo	34.86±36.30
Chemotherapy	73
Hormonotherapy	58
Axillary nodes dissection	53

The mean duration to complete reconstruction was 17.0 ± 10.0 months, with an average follow-up of 26.7 ± 16.2 months. The mean interval between the first and second procedures was 5.3 ± 4.3 months. The average total hospital stay was 14.2 ± 4.1 days. During the second procedure, all patients underwent contralateral breast symmetrization, abdominal scar revision, and burial of the DIEP flap skin paddle. Most patients also benefited from an initial lipofilling session. A third procedure was performed in all but 9 patients: 4 due to flap failures, 3 who had the NAC reconstructed during the second surgery, and 2 who opted for an artistic tattoo instead of NAC reconstruction. The third procedure primarily involved breast lipofilling, NAC reconstruction, refinements to the abdominal scar and contralateral breast, and IMF redefinition. A fourth procedure was performed in 48 patients, with an average of 3.4 procedures required to complete the reconstruction process. In this series, the TAAF achieved a 100% success rate, with no cases of necrosis or other complications reported. Additionally, one-third of the patients required an IMF redefinition (Fig. 3). One partial flap necrosis and 3 total flap losses were recorded, for which secondary reconstruction was achieved using the TAAF combined with lipofilling, a silicone implant, or a muscle-sparing latissimus dorsi flap^16–20 (Table 2). (See figure, Supplemental Digital Content 2, which displays the interventions performed during the second [T2], third [T3], and eventual fourth [T4] procedures, https://links.lww.com/PRSGO/E208.) No complications were observed in patients who underwent homolateral DIEP and thoracoabdominal flaps. One case of pulmonary embolism and 1 case of heparin-induced thrombocytopenia were promptly detected and effectively treated.

Fig. 3.

Representative case of unilateral delayed breast reconstruction using the DIEP–TAAF technique. Preoperative (A) and 1-year postoperative (B, C) photographs.

Table 2.

Complications

Complication	Incidence
Breast
Partial flap loss	1
Total flap loss	2
Fat necrosis	4
TAAF necrosis	0
Hematoma	3
Return to operating room	6
Venous occlusion	1
Abdomen
Abdominal hernia	2
Abdominal bulging	6
Seroma	4
Hematoma	1
Wound dehiscence	7
Umbilical necrosis	0
Infection	0

Of the 100 patients included in the study, 51% returned a postoperative BREAST-Q questionnaire. Preoperative questionnaires were not consistently available and were not reported. The highest scores were observed for physical well-being in the chest and abdomen modules, with mean values of 78.0 ± 18.6 and 72.2 ± 18.6, respectively. Satisfaction scored a mean of 63.3 ± 12.0 for the breast module and 9.3 ± 1.9 for the abdomen. Postoperative scores are listed in Table 3.

Table 3.

Postoperative BREAST-Q Scores

Modules	Value
Psychosocial well-being	69.7±16.1
Sexual well-being	55.7±18.2
Physical well-being: chest	78.0±18.6
Satisfaction: Breast	63.3±12.0
Physical well-being: abdomen	72.2±18.6
Satisfaction: abdomen	9.3±1.9

DISCUSSION

The DIEP flap is one of the most popular options for autologous breast reconstruction, offering excellent outcomes with the conventional approach. Although it fulfills the principle of reconstruction using the same tissue, the use of an abdominal skin patch⁴ deviates from the principle of reconstructing the breast envelope with adjacent teguments. Our experience, along with previous reports,²¹ demonstrates that the TAAF is highly effective in both immediate and delayed breast reconstruction, including cases following radiation therapy, as long as the skin is not severely damaged. The robust vascularization of the TAAF allows it to endure disruption of the internal mammary–deep inferior epigastric vascular axis, even during homolateral or bilateral DIEP flap procurement.^22–32 Thoracoabdominal skin trophicity and laxity are key determinants in patient selection for this procedure. During the initial consultation, in addition to prescribing a contrast computed tomography scan, methods to further improve thoracoabdominal skin laxity are recommended until the intervention. These include physiotherapy, self-massage, and the use of an external silicone implant adherent to the skin. A second preoperative consultation is dedicated to locating and selecting the DIEP perforator and assessing the feasibility of the TAAF using a cephalic traction maneuver, simulating TAAF elevation.

Minor postoperative dimpling dissipates within a few months, and persistent irregularities or eventual lack of definition of the IMF can easily be revised during a subsequent procedure for a lasting result. Hartrampf zone IV¹⁰ preservation during the first procedure reduces caudal traction on the reconstructed IMF and eliminates the need for overcorrection. The DIEP flap serves as a recipient vascularized matrix for the fat procured during secondary and systematic aesthetic lipoabdominoplasty. This approach allows for minimizing the DIEP flap size, improving viability, and reducing abdominal tension. We almost always perform buried flaps to eliminate the drawbacks associated with an abdominal skin paddle. Over 70% of our reconstructions use the DIEP–TAAF technique. In cases where local conditions are unsuitable for TAAF elevation—primarily due to severely irradiated skin with adherence and low elasticity, as revealed by the cephalad traction test—or when homolateral or bilateral reconstructions are required, skin expansion is favored. An additional TAAF is frequently performed following the thoracoabdominal skin expansion protocol in such cases. In this series, a few carefully selected patients underwent homolateral DIEP and TAAF procedures without complications, further underscoring the reliability of this technique. A comparison with the standard DIEP flap technique, which preserves the skin paddle, would have been valuable. However, such cases are now rarely performed in our department. In this study, the outcomes align with those reported by other authors, confirming the safety and efficacy of the DIEP–TAAF technique.^1,2,33,34 Notably, if the DIEP flap was lost, there was no skin defect to cover, and the TAAF could still be used for final reconstruction in all cases. However, 1 pitfall warrants mention: failure to perform the DIEP flap anastomosis to the internal mammary artery can complicate the use of axillary vessels due to obstruction by the TAAF extending toward the lateral mammary fold. Fortunately, no such cases occurred in this series.

Abdominal improvement is often cited as a benefit of DIEP flap reconstruction; however, the outcomes do not always align with patients’ expectations. Poor scar quality and position^35–37 may contribute to the differing preferences between patients and surgeons when selecting autologous reconstruction techniques,^36,38 and only a limited number of studies have explored methods to address these concerns. Some authors advocate modifying the DIEP flap design to lower the skin paddle and final scar. Although this approach can be highly effective in certain cases, it primarily addresses scar height and may occasionally compromise the vascular reliability of the DIEP flap.^11,39–42 Alternatively, the donut technique presents a particularly intriguing option, though it is suitable for a select group of patients.⁴³ Abdominoplasty-inspired techniques can be applied either at the end of the initial surgery^44,45 or during a systematic secondary revision of the donor site scar.⁴⁶ When performed during the first surgical stage, these techniques can significantly extend operating time, increase skin tension, and raise intra-abdominal pressure, which may not be suitable for cases involving bilateral DIEP flaps or concurrent TAAF procedures. Conversely, when implemented during a secondary procedure, the scar can be more easily lowered, and overall abdominal aesthetics improved. This standardized approach has the advantage of being adaptable to any DIEP flap breast reconstruction, especially if fully integrated with the reconstructive process. When designed independently of the primary surgery, a double umbilical transposition is necessary to avoid a vertical scar. Although no complications have been reported, severing both sides of the umbilical stalk during the 2 procedures may compromise its vascularization and the final abdominal result.^47–50 We propose an integrated multistage approach to abdominal management. The first stage focuses primarily on breast reconstruction and initial abdominal presetting, with the umbilicus transposed to a higher position to reduce tension and minimize the risk of a “string effect” between the TAAF anchoring point and a high-tension umbilical site. Such an adverse event is very rare and was not observed in this series but still highlights the learning curve of this technique. The second stage involves refinements to both the breasts and abdomen, with a revision aesthetic lipoabdominoplasty performed without umbilical transfer, ensuring no risk of IMF downward displacement. If present, abdominal bulging or hernias can also be addressed during the same operation. The third stage provides final touch-ups to achieve optimal results. The interval between the first and second procedures allows sufficient time for abdominal vascular autonomization, skin expansion, and the identification of any potential abdominal wall weaknesses. Additionally, the transposed DIEP flap has time to heal, facilitating lipofilling with fat harvested during the revision lipoabdominoplasty. In this way, correct placement of the abdominal scar can be achieved regardless of the BMI (even in relatively low-BMI patients where lowering the scar is known to be more challenging) and the perforator position. Our complication rate is similar to that found in the literature,^2,34 and patients’ reported outcomes seem to show high satisfaction. Our patients are informed that after the first procedure, the abdominal scar will be obliquely oriented with dog ears on the homolateral side of the reconstructed breast. With clear explanations, these temporary irregularities are generally well accepted.

Most of our patients had a history of parity, and the morphological breast and abdominal sequelae of motherhood are well recognized.⁵¹ Our technique offers patients not just a reconstruction but, to some extent, improvements relative to their postmaternal status. This multistep surgical protocol is specifically designed to address both concerns. In all cases, the abdominal scar was successfully lowered and concealed beneath undergarments (Fig. 4). High BREAST-Q scores for abdominal well-being and satisfaction modules, combined with a low morbidity rate, further validate this approach. Our BREAST-Q scores were comparable to those reported in the literature. (See table, Supplemental Digital Content 3, which displays BREAST-Q modules from large population studies on standard DIEP flap breast reconstruction, https://links.lww.com/PRSGO/E224.) One of the potential drawbacks of this technique is the number of procedures required and the total duration of hospital stay, which may raise concerns about associated costs. In France, the entire reconstructive process is fully covered by the national health insurance system, making this approach accessible to all patients. However, this may not be the case in other countries, where the technique could be more challenging to implement within different healthcare models. One strategy to address this issue is the implementation of enhanced recovery after surgery protocols, which have been shown to significantly reduce hospital stays and improve overall efficiency.^52,53 Although the multiplicity of procedures required might be seen as a drawback, our experience suggests otherwise. Adequately informed patients rarely express dissatisfaction, as it is well recognized that patient satisfaction often improves over time.^54,55 Additionally, satisfaction may increase with the number of procedures,⁵⁶ as patients come to appreciate the balance between the multistep protocol and its long-term benefits.

Fig. 4.

Photographs of the 1-year postoperative result. Note the scar on the underwear markings (A); the breasts are slightly ptotic (B), and the silhouette is well defined (C).

CONCLUSIONS

Breast reconstruction surgery aims to address patients’ morphological needs, enhancing body image and quality of life. Ideally, the procedure should deliver aesthetically pleasing, long-lasting results with minimal morbidity. From our perspective, the TAAF is a versatile technique that can complement all types of breast reconstruction, including DIEP flaps. The operative sequence is specifically designed to achieve aesthetically satisfying breast and abdominal outcomes, contributing to overall cosmetic improvement. The procedure remains safe even in the event of DIEP flap failure, as no defect is created on the chest. This study demonstrated that the appropriately sequenced DIEP–TAAF protocol is a reliable and effective approach for delayed unilateral breast reconstruction.

DISCLOSURE

The authors have no financial interest to declare in relation to the content of this article.