Immediate Breast Reconstruction with Deep Inferior Epigastric Perforator Flap in a Patient with Previous Surgical Correction of Pectus Excavatum : Plastic and Reconstructive Surgery – Global Open

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Breast: Case Report

Immediate Breast Reconstruction with Deep Inferior Epigastric Perforator Flap in a Patient with Previous Surgical Correction of Pectus Excavatum

Piccolo, Paulo P. MD*; Nahabedian, Maurice Y. MD, FACS; Venturi, Mark MD, FACS; Mesbahi, Ali MD, FACS

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Plastic and Reconstructive Surgery - Global Open 10(12):p e4725, December 2022. | DOI: 10.1097/GOX.0000000000004725
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Pectus excavatum (PE) is a deformity of the chest wall characterized by a sternal depression and possibly cardiac and pulmonary compression. The two main surgical approaches for correction of this deformity are the Nuss and the Ravitch procedures.1,2 The Ravitch procedure is considered a more invasive procedure because it may require excision of abnormal cartilage, repositioning of the sternum with or without ostetomies, and major instrumentation through a large chest incision, whereas the Nuss procedure involves placing a curved metal bar underneath the sternum, with the objective of pushing the abnormal structure out and improving the contour of the chest wall. This bar is positioned through small lateral chest wall incisions.

Prior repair of a PE deformity may pose challenges for plastic and breast surgeons alike due to potential shift of known anatomical structures such as the internal mammary (IM) vessels, breast tissue, thoracic musculature, and bony structure. Although, from the plastic surgeon’s perspective, this may not be as relevant for prosthetic breast reconstruction, it is important in the setting of autologous microvascular breast reconstruction.

We present a case report of a 45-year-old woman who has had prior surgical repair of PE, with new diagnosis of right breast cancer scheduled for bilateral nipple-sparing mastectomy and immediate reconstruction using a deep inferior epigastric perforator (DIEP) flap.


A 45-year-old woman presented with diagnosis of right breast ductal carcinoma in situ. The patient refused device-based reconstruction and instead chose bilateral nipple-sparing mastectomy with DIEP flap reconstruction.

The patient’s medical history was remarkable for PE deformity, which was surgically repaired with a Ravitch procedure at the age of 12 years.

Clinical examination (Fig. 1) revealed normotrophic breasts, grade I-II ptosis and no gross chest wall deformity. A transverse scar following the patient’s costal margin was noted. Abdominal examination demonstrated moderate lipodystrophy and skin laxity with diastasis recti. No hernias or masses were identified on physical examination.

Fig. 1.:
Preoperative image. Transverse scar is evident in upper abdomen/lower chest.

Given her thoracic surgical history, the ability to use the IM vessels as recipients for microvascular anastomosis was questioned. Computerized tomographic angiography (CTA) demonstrated normal DIEP anatomy and postsurgical changes from prior correction of PE (no hardware was present) with an associated fat-containing ventral hernia extending to the chest wall along the right heart border. The inferior aspect of the right internal mammary artery was displaced, and the left internal mammary artery was of small caliber (Fig. 2). Thus, the decision was made to proceed with DIEP flap reconstruction using the IM vessels as the primary recipient vessels and the thoracodorsal vessels as a back-up.

Fig. 2.:
Preoperative CTA images showing ventral hernia with extension to the chest (yellow circle).

During the left mastectomy, the chest wall component of the ventral hernia was visualized, with the fat-containing hernia evident and the heart immediately posterior to it. This hernia was noted to be in the fifth intercostal space, in an area where no intercostal muscle was present and with an abnormal costal origin of the pectoralis major muscle (Fig. 3).

Fig. 3.:
Intraoperative picture showing chest extension of ventral hernia with heart immediately underneath it (asterix); abnormal origin pectoralis major muscle (stars).

Bilateral DIEP flaps were raised uneventfully. The dissection of the right and left IM vessels posed no abnormalities and were routine. The vessels were of small caliber but responded to topical vasodilators, which allowed for an end-to-end venous anastomosis using a 2.0-mm coupler and an uneventful end-to-end arterial anastomosis with 8-0 Nylon. At closure, a small 2 × 10 cm skin island of the flaps was exteriorized for monitoring.

The patient’s immediate postoperative course and follow-up were unremarkable. A revision surgery was performed approximately 5 months after the original surgery for breast flap skin paddle excision and abdominal donor site revision (final result at 8 month follow-up seen in Fig. 4).

Fig. 4.:
Postoperative picture at 8 months follow-up.


Reports on free tissue transplantation for the correction of congenital chest wall deformities have been previously described.3–8 Some case reports have specifically addressed breast reconstruction in PE patients with autologous free tissue transfer.7,8 These studies, however, have not reported on reconstruction performed in patients who have had prior surgical correction of PE, nor have they reported on the use of the IM vessels as recipients for microvascular anastomosis. This case report highlights the salient aspects of free flap breast reconstruction after prior repair of PE.

The first consideration is to properly analyze the chest and upper abdominal anatomy. Procedures for correction of PE during childhood may cause local anatomical distortions. For this reason, the use of preoperative imaging such as a CTA of the abdomen and the chest is recommended. The benefits of preoperative imaging for abdominal perforator identification and selection have been well described; however, it is also important to identify abdominal defects in the epigastric area such as the one visualized in this case. More importantly, the chest CTA serves the purpose of checking for patency, caliber, and anatomical position of the IM vessels commonly used as recipient vessels.

Another key factor is clear communication with the breast surgery team. Operating on patients with PE (previously repaired or not) may pose severe challenges for the breast surgeons due to local anatomical distortions.9 The results of the CTA had been clearly communicated with the team; therefore, they were aware of the potential for exposure of the hernia during the mastectomy and how close the heart would be to their plane of dissection.

Finally, setting proper patient expectations is of utmost importance. The results of preoperative imaging and anatomical abnormalities were discussed with the patient. The patient was made aware that the asymptomatic ventral hernia would not be repaired during the index operation due to the risk of increased donor site morbidity and flap failure.


The free DIEP flap should be contemplated as a viable option for immediate breast reconstruction in the setting of previously corrected PE. The IM vessels can still be considered as the main recipient vessels in these cases. Preoperative vascular imaging is strongly recommended for preoperative planning and proper anatomy delineation.


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Copyright © 2022 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.