Deep inferior epigastric perforator flap in breast reconstruction: Experience with the first 50 flaps

Abdominal wall function is a major concern for plastic surgeons performing breast reconstruction with. TRAM flaps. The deep inferior epigastric perfor ator (DIEP) free flap spares the whole rectus abdominis muscle, includes sk in and fat only, and therefore, preserves adequate abdominal wall competenc e. Between January of 1995 and May of 1997, a total of 50 breast reconstruc tions in 42 patients were performed by using the DIEP flap. Eight patients had bilateral procedures. Five breast reconstructions were immediate and 45 were delayed. All patients were collected prospectively and no patients we re excluded from this study. The average age of patients was 47 years (rang e, 22 to 59 years) and the average weight was 65 kg (range, 51 to 103 kg). Seventy percent of patients had one or more risk factors for TRAM flap reco nstruction. The mean postoperative follow-up period was 13 months (range, 3 to 30 months). Twenty consecutive patients (17 single and 3 bilateral DIEP flap breast reconstructions) within this group underwent evaluation of the ir abdominal wall function preoperatively and then 3 and 6 months postopera tively by using Lacote's muscle grading system. Average flap harvesting tim e was 120 minutes and average blood loss was 420 cc. Total flap loss and pa rtial necrosis occurred in one (2 percent) and three flaps (6 percent), res pectively. Abdominal wound infection occurred in seven patients (17 percent ). Unfortunately, one patient died of adult respiratory distress syndrome o n the seventh postoperative day. Fat necrosis was found in three flaps (6 p ercent). Postoperative abdominal wall examination did not reveal any hernia , but bulging was found in two patients (5 percent). All patients were able to resume their daily activities. Abdominal wall function tests in the ser ies of 20 patients showed that all patients had reached or even improved th eir preoperative level of upper and lower rectus muscle function 6 months a fter the operation. The external oblique muscles were the most affected by the procedure of flap harvesting, but only two patients (10 percent) were f ound to have a measurable impairment after 6 months. Patient satisfaction w ith the reconstructed breast and the donor site was rated high. The free DI EP flap is, therefore, a reliable and valuable method of breast reconstruct ion. The donor site morbidity,vas decreased, and the more tedious flap diss ection did not affect the overall outcome.