Advances in Plastic & Reconstructive Surgery © All rights are reserved by Roman Romansky et al.

*Address for Correspondence: Dr. Roman Kirilov Romansky, Head of Department of Plastic Reconstructive Surgery, Medical University, University Hospital “Alexandrovska”, St.Georgi Sofiiski str. No1, Sofia, 1431, Bulgaria, Tel: +359 898510415; E-Mail: r.romansky@gmail.com

Received: March 18, 2018; Date Accepted: April 04, 2018; Date published: April 05, 2018.

Roman Romansky*, Evgeni Sharkov, Stefan KomitskiDepartment of Plastic Reconstructive and Aesthetic Surgery, Medical University Sofia, Bulgaria.

AbstractThe article focuses on a relatively rare occasion of a partial necrosis of free deep inferior epigastric artery perforator flap (DIEP) for breast reconstruction. In the case presented DIEP flap was used for delayed reconstruction of the right breast, following modified radical mastectomy. Substantial partial flap necrosis, requiring secondary surgery, was observed in the early postoperative period involving approximately 1/3 of the volume of the reconstructed breast. Final reconstruction was accomplished with latissimus dorsi pedicle myoucutaneous flap (LTD) Outcome and overall treatment is discussed in the light of the contemporary surgical practice.

Keywords: Free Flap; Partial Necrosis; DIEP Flap; LTD Flap.

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Case Study ISSN: 2572-6684

Partial Necrosis of DIEP Flap for Delayed Breast Reconstruction Comple-ting Autologous Reconstruction with LTD Pedicled Flap

Case report

42 years old woman, nonsmoker with acquired breast asymmetry [Figure 1] following modified radical mastectomy performed 3 years before primary consultation. Patient was subjected to chemotherapy and radiotherapy following mastectomy operation. Surgical plan was done to reconstruct the breast with DIEP flap. Preoperatively hand-held Doppler was used to determine the perforators. Intraoperatively flap was harvested based on two perforators from lateral row over the right rectus abdominis muscle. Zone IV was partially discarded. Flap was transferred to the recipient site and revascularized by means of end to end anastomosis of a. and v. epigastria inferior to internal mammary artery and vein with 9/0 Ethilon (Ethicone) sutures. Breast mound was created after deepithelialization of skin below maste-ctomy scar to the new inframammary fold. On the first day post op, change of skin color was observed related to insufficient venous outflow in the lower lateral third of the flap, involving part of Zone II and the residual part of Zone IV. Early revision surgery was not undertaken, because no suitable superficial epigastric vein was available in the flap. Medical treatment followed our standard protocol of low molecular weight heparin once per day for a week after surgery. By the end of the second week after flap transfer, demarcated fool thickness skin necrosis developed, involving approximately 1/3 of the breast surface. Patient was scheduled for revision surgery involving necrectomy and reconstruction with pedicled LTD myocutaneous flap, executed on 19th day post op [Figure 2]. Postoperative period was uneventful and the second flap survived completely. In order to obtain breast symmetry, six months later the right nipple areolar complex (NAC) was reconstructed, simultaneous with periareolar mastopexy on the left side. Postope-rative period was uneventful and patient was satisfied with the late result [Figure 3].

Discussion

There is no definitive description of partial flap loss in terms of relatively how much of the flap volume or surface is lost. Blondeel [3] for example considers any necrosis of more than 5% of the skin island as partial flap loss. Technically, fat necrosis in DIEP flaps, might as

Introduction Free tissue transfer is sophisticated and highly demanding surgical

method of treatment for difficult soft tissue and compound defects with various etiology. Microvascular free flaps are highly reliable with overall flap success rate of over 95% worldwide in expert hands [1, 2, 3]. Some clinical centres report an even higher rate of flap survival - over 99% [4]. Concerning breast reconstruction both in immediate and delayed setting, DIEP flap since its introduction by Allen and Treece [5] has become by far the best option to restore the breast mound with minimal donor site morbidity when reconstruction with prosthesis is not advantageously feasible. Compared to the alternatives like pedicle and free TRAM flaps, perforator flaps do not sacrifice any part of the rectus abdominis muscle and abdominal wall strength is fully preserved. Partial flap necrosis in DIEP flap breast reconstruction is generally very seldom, varying in large series 2, 5-7% [1, 3, 4]. Traditionally major free flap complications, including total and partial flap loss are accounted to technical error, as result of inexperience mainly during the learning curve period in microsurgery.

When a substantial part of flap necrosis occurs, requiring a secondary surgery to accomplish reconstruction, it is advisable to have a reserve plan. For breast reconstruction an excellent salvage option is pedicled LTD flap. It is available provided the thoracodorsal vessels on the side of reconstruction are preserved. For that reason our preference, in cases of free flap breast reconstruction, is strongly towards internal mammary artery and vein as recipient vessels. In our patient successful autologous breast reconstruction with good symmetry was achieved by means of DIEP and LTD flaps.

Adv Plast Reconstr Surg, 2018 Page 192 of 194

Figure 3a and 3b: Late postoperative result at 9 months after reconstruction.

Roman R, Evgeni S, Stefan K. Partial Necrosis of DIEP Flap for Delayed Breast Reconstruction Completing Autologous Reconstruction with LTD Pedicled Flap. Adv Plast Reconstr Surg, 2018; 2(2): 192-194.

Figure 1a

Figure 1a and 1b: Patient scheduled for DIEP flap reconstruction – preoperative markings.

Figure 2b

Figure 3a

Figure 2a nd 2b: Partial flap loss, scheduled to complete the reconstruction with LTD

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Figure 1b

Figure 2b

Figure 3b

Roman R, Evgeni S, Stefan K. Partial Necrosis of DIEP Flap for Delayed Breast Reconstruction Completing Autologous Reconstruction with LTD Pedicled Flap. Adv Plast Reconstr Surg, 2018; 2(2): 192-194.

well be considered as partial flap loss. It happens in between 6 and 13% of patients, but it is still less common than in pedicle TRAM flap breast reconstructions. Fat necrosis of DIEP depends on multiple factors and is significantly more common in smokers and in patients that have undergone radiotherapy or to be subjected to it in cases of immediate reconstruction. To our opinion partial flap loss should be defined only in cases that include full thickness skin necrosis of the flap requiring surgical treatment. Wound dehiscence and circu-mscribed edge necrosis should be excluded, despite the fact, that it might also be approached surgically. We consider as partial loss, necrosis of more than 12% flap skin, which is not expected to heal by secondary intention. Gill et al [4] find relationship between flap survival and number of perforators included in the DIEP, with the higher number of perforators, the higher probability to vascular complication and flap loss is present. On the other hand Blondeel [3] in a series of 100 DIEP flaps finds correlation between abdominal scarring and lower success rate. In addition, according to the author, if a perforator from the lateral row is selected as nourishing flap vessel, the higher the risk for partial necrosis of the distal contrala-teral side. Other less common factors that could lead to flap loss are high grade infection and mechanical pressure or trauma in proximity of the anastomoses caused by hematoma or avulsion [2].

DIEP partial flap loss rate can be substantially reduced if zone IV is totally discarded after harvesting the flap. Another option is to take a perforator from the contralateral side and anastomose it to the main pedicle [6]. Venous congestion might successfully be prevented or treated postoperatively with additional venous anastomoses, to the internal mammary or other recipient vein when superficial epigastric vein is present. That secures overall flap survival [7, 8].

Similar to other authors we prefer as recipient vessels the internal mammary artery and vein [3, 4, 5, 7]. By sparing the thoracodorsal pedicle, we have pedicle latissimus dorsi flap as a reserve in case of unsuccessful free tissue transfer. In the case presented study, the LTD [9] was utilized as salvage flap to complete the autologous breastreconstruction after partial necrosis of DIEP flap. Second free flap,like transverse gracilis (TUG) myocutaneous flap [10] can certainlybe used as an alternative. Our choice for LTD is justified by vast

experience with the technique, including over 100 cases with very low donor side morbidity. In addition for that particular case we needed more volume than could be provided by pedicled thoraco-dorsal perforator (TDP) flap, which is also an excellent option for partial breast reconstruction [11]. Finally the will of the patient for safe surgery and refusal to undergo second microsurgical reconstruction should also be taken into consideration, when dealing with big complications.

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