Thermal injuries in the insensate deep inferior epigastric artery perforator flap: Case series and literature review on mechanisms of injury

Abstract

With the increasing use of the deep inferior epigastric artery perforator (DIEP) flap, complications that are particularly rare (less than 1%) may start to become clinically relevant. During DIEP flap harvest, cutaneous nerves innervating the flap are necessarily sacrificed, resulting in reduced sensibility. This impaired sensibility prevents adequate thermoregulatory reflexes, like vasodilatation, sweating, and protective behaviors, leaving the reconstructed breast considerably more susceptible to thermal insult. We present four DIEP flap cases who sustained postoperative thermal injury to the reconstructed breast. All four cases were operated on between 2001 and 2008, over the course of 600 DIEP flaps in our unit (an incidence of 0.7%). The injuries occurred between 2 and 18 months after reconstruction. Two patients sustained thermal injury while sunbathing, one while staying in a warm environment, and one sustained the injury while taking a shower. No flap losses ensued, but these were not without morbidity. A literature review discusses other similar cases in the literature and describes the mechanisms for these findings. As a majority of patients will regain both fine-touch and heat sensation by 3 years postoperatively, it is pertinent that prophylactic measures be instituted during this period, such as the avoidance of sunbathing and the use of cooler shower temperatures for the first 3 years postoperatively. While performing sensory nerve coaptation is the gold standard for maximizing the success of sensory regeneration, this is not always sought and the 0.7% incidence of thermal injury we have encountered suggest the role for greater consideration of such injury.