Factors that predict deep inferior epigastric perforator flap donor site hernia and bulge

Abstract

Deep inferior epigastric artery perforator (DIEP) flap has become the gold standard in autologous breast reconstruction. Attention is now being focused on the impact of DIEP flap harvest technique on abdominal hernia rates. The aim of this study was to evaluate DIEP abdominal wall morbidity in relation to flap harvest and fascial closure technique. A retrospective analysis of patients undergoing DIEP flap breast reconstruction between 2012 and 2016 was performed. Post-operative evaluation of the abdominal wall integrity was performed by an operating consultant. The rectus fascia was closed using one of three techniques. The study included 202 patients, in whom 234 DIEP flaps were performed. Eight patients (3.4%) developed a clinically evident abdominal bulge post-operatively and one (0.5%) had a hernia. Harvesting two or more perforators was more likely to result in post-operative abdominal hernia/bulge than taking a single perforator (p = .032). Using a perforator from the lateral row or both rows was more likely to result in a hernia/bulge than if a single medial perforator was harvested (p = .026). Comparison of the rectus fascia closure technique did not show any statistically significant difference in abdominal wall morbidity. Consideration should be given towards perforator selection when harvesting a DIEP flap. Where appropriate, a suitable single medial row perforator with a favourable suprafascial course should be chosen. This study has not shown mesh-free fascial closure to be inferior to mesh-supported closure. Careful consideration to the role of synthetic mesh within this patient cohort should be given.

Donor site aesthetics and morbidity after DIEP flap breast reconstruction—A retrospective multicenter study

“…Our incidence of 7% is well in line with these studies. Similar to previous studies, we could observe a significant correlation between abdominal bulge and two or more perforators 11 . Considering that the dissection of a flap, based on two perforators, will harm the rectus fascia to a greater extent, an impairment on abdominal wall integrity seems plausible.…”

“…We further observed an increased incidence of abdominal bulge in patients with a higher BMI. Although a similar correlation was reported by other authors, a higher BMI might bias the need for two or more perforators 11,17 . It is well known that the contribution of the deep and the superficial system to the perfusion of the lower abdomen is inversely related 18,19 .…”

“…Perforator localization remains a further matter of debate. Whereas previous studies observed a strong correlation between abdominal bulge and lateral row perforators, others refuted any connection 11‐15 . Our results also show a significantly higher risk of abdominal bulging after using lateral row perforators.…”

The feasibility and safety of immediate breast reconstruction in the COVID-19 era

“…It is imperative, however, to educate all the patients of this potential risk and a possible increased risk of hernias due to fascial dehiscence. 35…”

Combining the superficial circumflex iliac artery perforator flap with the superficial inferior epigastric artery flap or the deep inferior epigastric artery perforator flap for coverage of large soft tissue defects in the extremities and the trunk

“…When a perforator from the DIEA has to be included, the dissection is limited to its take off point, with a small T‐portion obtained from the DIEA. Butler et al (2018) reported in their retrospective analysis of 234 DIEP flaps that taking a single perforator was less likely to result in postoperative hernia or bulging than taking two or more perforators. Thus, we believe our method minimizes the risk of postoperative herniation and bulging.…”