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Techniques and Perforator Selection in Single, Dominant DIEP Flap Breast Reconstruction: Algorithmic Approach to Maximize Efficiency and Safety

Mohan, Anita T. M.R.C.S., B.Sc.; Zhu, Lin M.D.; Wang, Zhen Ph.D.; Vijayasekaran, Aparna M.B.B.S., M.Sc.; Saint-Cyr, Michel M.D.

Plastic and Reconstructive Surgery: November 2016 - Volume 138 - Issue 5 - p 790e-803e
doi: 10.1097/PRS.0000000000002716
Breast: Original Articles

Background: Perforator selection is critical to deep inferior epigastric perforator (DIEP) flap harvest. Commitment to a single perforator has the potential benefit of a simpler dissection, but may increase fat necrosis or perfusion-related complications compared with multiple perforator harvest.

Methods: A 3-year retrospective study was carried out of all patients who underwent DIEP flap breast reconstruction performed by the senior author (M.S.-C). Data were collected on patient demographics and surgical outcomes.

Results: One hundred eighty-three flaps were performed (105 patients) over 3 years. One hundred fifty-six bilateral (78 patients) and 24 unilateral flaps were included in the final study. Mean age was 47.8 ± 8.4 years and mean body mass index was 29.1 ± 5.3 kg/m2. Seventy-five percent of flaps were based on single dominant perforators. Single perforators were used in 33.3 percent of flaps weighing over 1000 g, 80 and 74 percent of flaps weighing 500 to 1000 g and less than 500 g, respectively (p = 0.01). There were no differences in overall complications between single- versus multiple-perforator DIEP flaps. Neither body mass index nor flap weight posed additional risk to overall complications. Conversion to a muscle-sparing flap was 9.4 percent.

Conclusions: The authors present an algorithm for perforator selection, stepwise approach to flap harvest, and considerations for intraoperative decision-making in DIEP flap reconstruction. Single–dominant perforator flaps can be safely performed, but inclusion of the largest perforator is critical to flap perfusion. Additional perforators must be weighed against the associated tradeoff with donor-site morbidity. The threshold for conversion to a muscle-sparing flap is reduced with increased clinical experience.


Rochester, Minn.; and London and Cambridge, UnitedKingdom

From the Division of Plastic Surgery and the Division of Health Care Policy and Research, Department of Health Sciences Research, Mayo Clinic; the Restoration of Appearance and Function Charitable Trust; and the Department of Surgery, University of Cambridge.

Received for publication November 8, 2015; accepted June 23, 2016.

Disclosure:Dr. Saint-Cyr is a consultant for Pacira. The other authors have no financial or commercial information to declare.

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Michel Saint-Cyr, M.D., Division of Plastic Surgery, Scott & White, 2401 South 31st Street, Temple, Texas 76508,

Copyright © 2016 by the American Society of Plastic Surgeons