Algorithm for the Transfer of Abdominal Tissue for Breast Reconstruction in Cases of Previous Abdominal Surgery

Multiple techniques exist for transfer of lower abdominal tissue for breast reconstruction: pedicled and free TRAMs, DIEP, or SIEA flaps. However, the ideal vascularity in cases of previous abdominal surgery has not been explicitly defined. The authors presented their past 3-year experience in breast reconstruction using lower abdominal tissue, and provided an algorithm for the determination of the preferred flap in cases of previous abdominal scarring from Pfannensteil, McBurney, Kocher, midline, paramedian, or laparoscopic incisions.

Preoperatively, it was anticipated that all patients would undergo free tissue transfer (DIEP flap preferred). Microvascular transfer was possible in all but two patients (lack of recipient vessels in a severely irradiated chest and a lower lateral paramedian incision for appendectomy that had transected the deep inferior epigastrics). No other scars, including Kocher and McBurney incisions, precluded free tissue transfer. Previous laparascopic surgery had no effect on choice of flap.

Pfannensteil incisions were of importance: SIEAs were universally divided, whereas DIEAs were not. However, lower lateral and mid-to-low medial row perforators were not reliable perforators on which to base DIEP flaps, and resulted in inadequate flap vascularity, increased incidence of fat necrosis, need for venous supercharge from the superficial system, or conversion to free TRAM. When a lower midline incision was present, medial row perforators were less likely to be available for supplying the DIEP flap, so that lateral row perforators were usually selected.

This summary was used to develop guidelines for flap dissection and selection for breast reconstruction in cases of previous abdominal surgery.