An Idea of Hemi-abdominal Free Flap for Breast Reconstruction: A Case Report

Summary:

A deep inferior epigastric perforator (DIEP) flap is one of the gold standards for autologous breast reconstructions. However, this flap cannot be chosen again if asynchronous contralateral breast cancer occurs in the future. To solve this problem, we propose an idea and design for a hemi-abdominal DIEP flap. The patient was a 50-year-old woman who was suffering from right invasive ductal carcinoma. In using a hemi-abdominal DIEP flap, the poor postoperative appearance of the donor site might be a problem. To obtain a good donor site shape, we use a specific design to make the appearance of the donor site as good as possible. Specifically, we make an oblique spindle-shaped flap that can cover the deep inferior epigastric perforators, the superficial circumflex iliac artery, and the superficial inferior epigastric artery and avoid dog-ears, without passing over the median line. The flap weight was 800 g, the operating time was 6 hours and 22 minutes, and the bleeding amount was 110 ml. The patient had a minor wound infection in the donor site, and it was treated with a local wound treatment. The patient is satisfied with the result. We believe our flap design could minimize the unfavorable appearance of the donor site. This method might be suited to cases where the patients present with excess skin and fat on the abdomen, and half the abdominal tissue is enough to create the necessary volume of the breast. Although more cases and studies will be required to justify our technique, this case may show the possibility of a new option for breast reconstructions.

A deep inferior epigastric perforator (DIEP) flap is one of the gold standards for autologous breast reconstructions because it gives satisfactory outcomes to patients with a relatively little donor site morbidity.^1–4 However, one of its drawbacks is that it is supposed to be used only once in the patient’s lifetime. In other words, a DIEP flap cannot be chosen again in the case of asynchronous contralateral breast cancer in the future.

To solve this problem, we propose the idea and design for a hemi-abdominal DIEP flap. In this article, we present our flap design, clinical experience, and indications for this technique.

PATIENT AND METHOD

At our institution, in the last 3 years, 286 patients underwent a unilateral breast reconstruction and 23 patients underwent a simultaneous bilateral breast reconstruction. In these cases, 2 cases underwent autologous breast reconstruction for the asynchronous bilateral breast reconstruction.

In this case, the patient was a 50-year-old woman with the combination of right invasive ductal carcinoma, cTisN0M0, stage 0, and extensive ductal carcinoma in situ (DCIS). This patient underwent right breast mastectomy, and immediate subpectoral tissue expander placement. Thirteen months after the operation, she chose to undergo an autologous breast reconstruction. She preferred to use her abdominal tissue for the reconstruction because she complained that she had a lot of fat tissue on her abdomen. Her breast dimensions were: width of 150 mm, projection of 68 mm, and ptosis of 3 cm. The patient was also concerned about future asynchronous contralateral breast cancer.

Considering the patient’s background and demands, a hemi-abdominal DIEP flap was planned for the surgery.

Because she had a medical history of asthma, computed tomography angiography of the abdomen was not carried out before the operation.

CASE REPORT

The day before the operation, 70 MHz ultrasound was used⁵ to detect and observe the running pattern of the superficial circumflex iliac artery (SCIA),^6,7 and the superficial inferior epigastric artery (SIEA).^8,9 Then, Doppler flowmetry was used to identify the deep inferior epigastric perforators. The flap was designed to have an oblique elliptical shape with the size of 13 × 20 cm², including these 2 vessels and DIEP perforators, ensuring enough volume for the planned breast reconstruction. This particular flap was designed on the one side of the abdomen. Finally, additional lines were marked to correct the dog-ear on each end of the design, but no part of the flap went over the mid-line (Figs. 1 and 2). The final flap size was 13 × 28 cm².

Fig. 1.

Preoperative design. The hemi-abdominal DIEP flap with the size of 13 × 28 cm². The blue circle in the middle shows the umbilicus, and the red line means the SCIA.

Fig. 2.

The schema of the flap design. ASIS, anterior superior iliac spine; FA, femoral artery; FV, femoral vein; SCIA, superficial circumflex iliac artery; SCIV, superficial circumflex iliac vein.

During dissection, the SIEA and the deep and superficial branches of the SCIA were found, but they were too thin to harvest as a flap pedicle. Therefore, we harvested the hemi-abdominal DIEP flap as we had planned. Indocyanine green angiography showed that the right perforator was enough to allow perfusion of the contrast liquid to almost the entire area of the flap except for a small part of zone III. The flap weight was 800 g. The deep inferior epigastric artery and vein were anastomosed to the right internal mammary artery and vein at the fourth intercostal space. The operating time was 6 hours and 22 minutes, and the bleeding amount was 110 ml.

The patient had a minor wound infection in the donor site on the ninth day after surgery, and it was treated with a local wound treatment and antibiotics. She was discharged on the 15th day after the surgery.

There have been no signs of recurrence or distant metastasis for the past 2 months, and the patient is satisfied with the result (Fig. 3). The contralateral side of her abdomen still has adequate volume without any operation scar, which means a contralateral hemi-abdominal DIEP flap could be harvested from this patient in the future.

Fig. 3.

Two months postoperative view of the patient after the surgery.

DISCUSSION

In 1989, when the first clinical use of a cutaneous-adipose flap from the lower abdomen with complete sparing of the transverse rectus abdominis muscle was presented by Koshima and Soeda,¹⁰ the DIEP flap has been widely used in breast reconstruction. Compared with musculocutaneous flaps such as the free transverse rectus abdominis myocutaneous flap, this flap has advantages of decreasing the possibility of ventral hernia and muscle weakness.¹¹ However, a disadvantage of the DIEP flap is that it is supposed to be used only once for the same patient.

When a patient has asynchronous contralateral breast cancer, there are some options for autologous breast reconstruction such as: profunda artery perforator flaps,¹² latissimus dorsi flaps,¹³ superior gluteal artery perforator flaps,¹⁴ and lumber artery perforator flaps.¹⁵ Colebunders et al¹⁶ reported the usage of a dog-ear flap supplied by perforators of the deep circumflex iliac artery for a patient who had a previous DIEP flap breast reconstruction. This flap could be a good alternative for a patient with asynchronous contralateral breast cancer, but Asian people do not have so much fat at the dog-ear site; so this technique has limited indications for Asian patients. The other option is to use stacked flaps. This method is useful for patients with a discrepancy between the amount of required tissue for adequate breast reconstruction and volume from a single donor site, but in this case, the volume of the tissue at only half abdominal was adequate.

In our case, the patient had several complaints concerning her breast: stiff shoulders caused by the weight of her breasts, and dermatitis in the inframammary folds caused by the ptosis of her breasts. Therefore, she wanted to make her breasts smaller and less ptotic than previously.

For the purpose of satisfying the patient’s request to use the abdominal tissue to make a breast that was not so large, while preserving the tissue in case of contralateral breast cancer in the future, a hemi-abdominal DIEP flap was chosen. Although using a hemi-abdominal DIEP flap would allow for use of the other side in the future, the poor postoperative appearance of the donor site, such as asymmetry in the abdominal shape and deviation of the umbilicus, might be a problem. To obtain a good donor site shape, we use a specific design to make the appearance of donor site as good as possible. Specifically, we make an oblique spindle-shaped flap that can cover the deep inferior epigastric perforators, SCIA, SIEA, and avoid dog-ears, without passing over the median line. We believe our flap design could minimize the unfavorable results on the donor site appearance.

In 2009, Shridharani et al¹⁷ reported the method of banking a hemi-abdominal DIEP flap, where they mentioned the utility of banking the contralateral hemi-abdominal DIEP flap under the abdominal closure in patients undergoing a unilateral autologous breast reconstruction. It means that the contralateral hemi-abdominal adipocutaneous flap is kept attached by all its major perforators after a microvascular transfer of the index hemi-abdominal flap, and the buried flap is used at reoperation. However, it was not for the asynchronous contralateral breast cancer in the future.

Not every patient is suited to this method. The necessary conditions for this method will be that the patient presents with excess skin and fat on the abdomen, and that half the abdominal tissue is enough to create the necessary volume of the breast. In some cases, the patient does not want the reconstructed breast to be of the same size as that of the other side; so the method should be chosen according to the patient’s needs. Although more cases and studies will be required to justify our technique, this case may show the possibility of a new option for breast reconstruction.