Outpatient Cosmetic Breast Augmentation with DIEP Flaps

Abstract

BACKGROUND: Breast augmentation ranks as one of the most commonly performed cosmetic procedures. It is a relatively inexpensive and straightforward procedure that yields good results with low risk. However, potential problems with implants exist such as deflation, leaks, malposition, pain, and capsular contraction. Breast Implant Illness (BII) or Breast Implant Associated Lymphoma (BIA-ALCL) remains a high concern for many patients. As a reliable alternative or treatment for these issues and concerns, the authors describe the use the deep inferior epigastric perforator (DIEP) flap in outpatient cosmetic breast augmentation and mastopexy. METHODS: We reviewed patients who had undergone cosmetic breast augmentation with DIEP flaps over a 12-month period. Any patient who desired breast augmentation, implant exchange, or augmentation mastopexy with concomitant abdominoplasty was considered a candidate for the procedure. Charts were reviewed for all patients who elected to proceed with cosmetic DIEP flaps. All patients underwent our early recovery protocol, including microfascial incisions to harvest the DIEP flaps, and rib preservation in addition to ERAS protocols with intraoperative anesthetic blocks. RESULTS: Eleven consecutive patients underwent bilateral cosmetic breast augmentation with DIEP flaps and mastopexy. Overall, all patients referred dissatisfaction with their abdomen and breasts. Three patients presented with ptotic breasts following recent pregnancies. Four patients were displeased with their breasts following augmentation with prosthetic implants. Three patients were experiencing pain and discomfort due to bilateral capsular contractures, with two of them being consistent with Breast Implant Illness. Lastly, one patient decided to undergo breast augmentation following bariatric surgery. Microfascial incisions for single perforator abdominal flaps (n = 17) averaged 1.7 cm (range 1.3–2.4), while flaps with multiple perforators (n = 5) averaged 2.4 cm (range 2-–2.5). Dissection of recipient IMA vessels was performed without disruption of the rib. No fascia or muscle tissue was taken during flap dissection. All patients had strong Doppler signals before discharge within 23 hours. No partial or total flap losses were reported, without major complications or take-backs. Average follow-up was 15 weeks. One patient required in-office debridement and closure due to suture granuloma at the abdominal incision. One patient developed minimal T-zone necrosis of the mastopexy site, which healed secondarily. Another patient, who had undergone prior mini-abdominoplasty, had limited flap edge necrosis that also healed secondarily. DISCUSSION: Combined breast augmentation or augmentation mastopexy with abdominoplasty is a commonly performed surgical procedure. Patients who desire abdominoplasty and augmentations are ideal candidates for this procedure. Breast augmentation with autologous tissue, particularly the DIEP flap, is an attractive option inherent to the additional abdominal tissue available to harvest. Likewise, women with implant complications like severe capsular contractures, or patients who have concerns for BIA-ALCL or have Breast Implant Illness, yet would like to maintain breast volumes, are excellent candidates. These conditions and the fear of these problems required other reliable options for breast augmentation or removal of implants secondary to refractory illness. Our early recovery protocol allows us to perform microsurgical breast reconstructions and augmentations in an outpatient setting, with outstanding results and no total or partial flap losses, thus offsetting the high costs associated with the DIEP flap.