Banking a DIEP Flap in High-Risk Patients: A New Technique during Unilateral DIEP Harvest

Abstract

Sir: The deep inferior epigastric artery perforator (DIEP) flap can supply a substantial volume of tissue with low donor-site morbidity. However, where there is a midline abdominal scar, safe use of more than one hemiabdominal wall on a single pedicle is not possible. In this setting, a decision must be made as to the use of the other hemiabdomen. Where additional tissue is of use as a reconstructive flap, the tissue can be supplied by an additional pedicle,1,2 as either a two-anastomosis bipedicled DIEP flap or a single-pedicle stacked DIEP flap. Where the additional tissue is not needed, it may be discarded. We describe an additional technique, in which the second hemiabdominal wall can be raised as a DIEP flap and advanced to the midline during closure. By banking a surplus DIEP flap, this “preharvested” flap can be used in a subsequent procedure if needed. Although not routine, we describe a unique case where this additional tissue was required to aid abdominal closure and as a future reconstructive flap in a high-risk setting. A 43-year-old woman presented for immediate, unilateral reconstruction of her chest wall. Her history included a midline open hysterectomy. She had previously undergone a mastectomy and axillary clearance for breast carcinoma, and presented with a local chest wall recurrence. A biopsy demonstrated mixed ductal carcinoma and lymphangiosarcoma. Staging magnetic resonance imaging scan demonstrated a 7-cm tumor, confined to the chest wall and infiltrating pectoralis major. Wide local excision of the lesion (including pectoralis major, periosteum, and a single rib) and reconstruction with a DIEP flap were performed, with more skin required than was available from a single hemiabdomen (Fig. 1). Given the previous midline abdominal surgery, a hemiabdominal wall flap was designed that was too large to facilitate direct closure. A right hemiabdominal DIEP flap was raised and used to reconstruct the chest wall defect (Fig. 2). The deep inferior epigastric artery and single vein were anastomosed to the circumflex scapula artery and vein.Fig. 1.: Chest wall defect after wide local excision of tumor, and abdominal wall flap design, with the right hemiabdomen marked to match the chest wall defect, given the midline scar.Fig. 2.: Intraoperative view of chest wall reconstruction with a right-sided hemiabdominal DIEP flap and closure of the abdominal wall with a left DIEP advancement flap.The left hemiabdominal wall was raised as a second DIEP flap and advanced to the midline to aid abdominal wall closure (Fig. 2). This flap was thus available for future use as a reconstructive flap in the case of further chest wall recurrence. Direct closure of the abdomen following DIEP flap harvest is essential to achieve good donor-site outcomes. Although few studies have described techniques of closure following DIEP flap harvest, techniques described to improve donor-site outcomes do include anterior rectus sheath plication, external oblique plication, and dermolipectomy.3–5 Although tension during closure is not sought, some cases often necessitate tight closure and require consideration of alternative options. We describe a new technique to aid abdominal wall closure, in which the portion of the flap not used in the reconstruction is advanced to the midline as a perforator flap, particularly suitable in cases of midline scars. This DIEP advancement flap has thus been preharvested for subsequent use as a free flap, appropriate in the current case, where the tumor was at high risk for recurrence and subsequent reconstruction may be required. Warren M. Rozen, M.B.B.S., B.Med.Sc., P.G.Dip.Surg.Anat. Iain S. Whitaker, B.A.(Hons.), M.A.(Cantab.), M.B.B.Chir. Thorir Audolfsson, M.D. Olafur P. Jakobsson, M.D., Ph.D. Marcus J. D. Wagstaff, B.Sc., M.B.B.S., Ph.D. Rafael Acosta, M.D. DISCLOSURE The authors declare that there is no source of financial or other support or any financial or professional relationships that might pose a competing interest.