It was with great interest that we read the article entitled “Medial Row Perforators Are Associated with Higher Rates of Fat Necrosis in Bilateral DIEP Flap Breast Reconstruction” by Kamali et al.1 The authors retrospectively reviewed their bilateral deep inferior epigastric perforator (DIEP) flap reconstructions at 10 years. A total of 728 hemiflaps were divided into three cohorts based on their perforator pattern: medial row perforators (30.9 percent), lateral row perforators (36.1 percent), and medial plus lateral row perforators (33.0 percent). There were no significant differences in terms of major perfusion-related complications except for fat necrosis that was significantly higher in flaps based on medial perforators. The authors concluded that if the dominant perforator is medial, one should include a lateral perforator to decrease fat necrosis.
Knowing that more perfusion is better, the issue that this study addresses is how we can provide the best flap perfusion while performing a muscle-sparing procedure. The DIEP flap is based on a deep inferior epigastric perforator (or perforators) that pierces the rectus muscle to supply the overlying skin and fat. In contrast to a transverse rectus abdominis musculocutaneous flap, no muscle or fascia is sacrificed to harvest a perforator flap.2 When performing the hemiflap based on lateral and medial row perforators, the rectus muscle is cut between the vessels to bring the rows together; the DIEP flap is no longer “muscle-sparing/muscle-preserving” and does not qualify as a perforator flap. To be considered a perforator flap, each perforator should be dissected in its own muscle septum, down to its takeoff at the deep inferior epigastric vessel with total muscle preservation. One pedicle is then transected, brought around the muscle, and reconnected under the microscope. Another way to improve perfusion is to perform a bipedicled stacked hemi–abdominal extended perforator flap, in which the main DIEP pedicle is attached to a secondary, lateral pedicle, usually the deep circumflex iliac artery.3 Preoperatively, we identify the site of vessel entry into the planned flap, the vessel diameter, and its arborization pattern with magnetic resonance angiography.4 We have performed tripedicle extended abdominal perforator flaps that use two secondary pedicles harvested without muscle sacrifice, most commonly the deep circumflex iliac artery and the superficial inferior epigastric artery. Gill et al., in their landmark article reviewing 10 years’ experience with DIEP flaps, showed that choosing a single, dominant perforator resulted in the least amount of fat necrosis.5 This is counterintuitive unless one understands that more perforators are harvested when there is a concern that there is no single dominant vessel to carry the flap. In these situations, it is acceptable to harvest more than one perforator, provided they occur in the same muscular septum.
Perforator selection is critical for minimizing fat necrosis, and we congratulate the authors on their findings. However, in cases where multiple perforators are used as recommended by the authors, the intervening muscle must not be sacrificed. Otherwise, we must be clear that the procedure being done is not a perforator flap. As perforator flap breast reconstruction surgeons, we should adhere to the perforator flap definition and continue to find ways to improve perfusion, without muscle sacrifice.
The authors declare no conflicts of interests with respect to the authorship and/or publication of this communication. The authors received no financial support for the research and/or authorship of this communication.
Joshua L. Levine, M.D.
Department of Plastic and Reconstructive Surgery
New York Center for the Advancement of Breast Reconstruction
New York Eye and Ear Infirmary of Mount Sinai Hospital
New York, N.Y.
Alexandra Condé-Green, M.D.
Department of Plastic and Reconstructive Surgery
Hackensack University Medical Center
1. Kamali P, Lee M, Becherer BE, et alMedial row perforators are associated with higher rates of fat necrosis in bilateral DIEP flap breast reconstruction. Plast Reconstr Surg. 2017;140:19–24.
2. Granzow JW, Levine JL, Chiu ES, Allen RJBreast reconstruction with the deep inferior epigastric perforator flap: History and an update on current technique. J Plast Reconstr Aesthet Surg. 2006;59:571–579.
3. Massey MF, Spiegel AJ, Levine JL, et alGroup for the Advancement of Breast Reconstruction. Perforator flaps: Recent experience, current trends, and future directions based on 3974 microsurgical breast reconstructions. Plast Reconstr Surg. 2009;124:737–751.
4. Agrawal MD, Thimmappa ND, Vasile JV, et alAutologous breast reconstruction: Preoperative magnetic resonance angiography for perforator flap vessel mapping. J Reconstr Microsurg. 2015;31:1–11.
5. Gill PS, Hunt JP, Guerra AB, et alA 10-year retrospective review of 758 DIEP flaps for breast reconstruction. Plast Reconstr Surg. 2004;113:1153–1160.
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