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PURPOSE:
Abdominal wall integrity is potentially compromised by damage that occurs during deep inferior epigastric perforator (DIEP) or muscle-sparing free transverse rectus abdominis musculocutaneous (MS FTRAM) flap harvest. However, information about how technique-related factors for DIEP and MS FTRAM flap harvest affect abdominal wall integrity is conflicting. Recent anatomic studies show the intercostal motor nerves to be closely associated with the lateral branch of the deep inferior epigastric artery (DIEA) and recommend surgeons favor medial DIEA branch perforator harvest to reduce abdominal bulge/hernia development. We hypothesized that patients who underwent breast reconstruction using fascia-sparing MS FTRAM flaps or DIEP flaps would have similar rates of abdominal wall hernia/bulging as long as perforators were harvested only from a single branch of the deep inferior epigastric artery (DIEA).
METHODS:
We evaluated 2043 consecutive abdominal-based free flap breast reconstructions performed between 2000 and 2010. Of these, we included only DIEP or fascia-sparing MS FTRAM flaps for which it could be confirmed that the flap had been harvested exclusively from either medial or lateral DIEA branch perforators. The primary outcome measures were the relationships between abdominal bulge/hernia and medial or lateral branch DIEA flap harvest, DIEP or MS FTRAM flap design, prior abdominal surgery, use of mesh, and number of perforators harvested. Unicovariate and multicovariate regression models were fitted to evaluate patient and reconstruction characteristics for potential independent predictive or protective associations with the development of abdominal bulge/hernia.
RESULTS:
We identified 615 flap harvest donor sites in 501 patients that met the criteria for study inclusion. Mean follow-up was 31 months. Patient demographics, reconstruction timing, DIEP versus MS FTRAM, unilateral versus bilateral distribution, and percentage of mesh closures were similar between the branch harvest groups. Abdominal bulge/hernia rates were similar between the medial (3.5%) and lateral (5.5%; p=0.20) branch donor sites as well as between the DIEP (3.9%) and MS FTRAM (5.8%; p=0.35) groups. The use of mesh (p=0.609) and number of perforators harvested (p=0.097) did not predict the development of abdominal wall bulge/hernia. Cases with prior abdominal surgery had a four-fold higher incidence of abdominal wall bulge/hernia (7.4% vs. 2.1%; p=0.002).
CONCLUSIONS:
When perforator harvest was limited to a single branch of the DIEA, the abdominal bulge/hernia rates were similar, whether the flaps were harvested on medial- or lateral-branch-only perforators, as DIEP or MS FTRAM flaps, or on single or multiple perforators. The only predictive factor for the development of abdominal wall morbidity was prior abdominal surgery. To our knowledge, this study is the largest patient series to date evaluating the effects of strict medial- or lateral-only DIEA branch harvest groups, DIEP versus MS FTRAM design, perforator number, and prior abdominal surgery on abdominal wall morbidity in free flap breast reconstruction patients. Contrary to what has been recommended by previous anatomic studies, surgeons should not favor medial DIEA branch perforator harvest in an effort to reduce abdominal bulge/hernia development. Instead, DIEA branch perforators should be harvested from the branch that provides the best quality perfusion to the DIEP or MS FTRAM flap.