CASE REPORT DIEP breast reconstruction following multiple abdominal liposuction procedures

Case 1

A 57-year-old woman underwent right mastectomy for invasive ductal carcinoma, and immediate reconstruction with latissimus dorsi flap and expandable implant in 2004, followed by adjuvant chemo- and radiotherapy. The patient had no significant medical history, took Anastrozole, and was a non-smoker.

The patient developed capsular contracture and underwent exchange of implant and simultaneous fat transfer (Coleman's technique) in December 2009. 240 mls of fat was harvested from the infra-umbilical abdomen. A second fat transfer in April 2010 harvested 300ml from the same site. Further loss of fat graft volume warranted a third fat transfer in December 2010, with 300 mls harvested from abdomen.

Thin skin overlying the implant and a recurrent capsular contracture 16 months later (Fig. 1) led the patient to request removal of implant and DIEP flap reconstruction.

Figure 1. Case 1 - Appearance of previously reconstructed right breast before revision reconstruction with DIEP flap.

Pre-operative CT angiography demonstrated normal-looking abdominal and perforator anatomy (Fig. 2). Intraoperatively, very minimal scarring from the liposuction was noted. A 610g DIEP flap was raised on a single, central, medial row perforator vessel, 3.2 mm in diameter, with no fat necrosis or delayed healing (Fig. 3).

Figure 2. Case 1 - Left sided perforator vessel supplying overlying skin and fat (arrow) on CT angiogram.

Figure 3. Case 1 - Appearance 5 months following DIEP flap breast reconstruction

A left symmetrising mastopexy and further fat transfer were performed in September 2012.

Case 2

A 54-year-old woman underwent wide local excision and adjuvant radiotherapy for an invasive ductal carcinoma of the right breast in 2006. Sentinel lymph node biopsy was negative. The patient had no significant medical history and was an ex-smoker. Due to scar tethering and volume loss she underwent a series of five lipofilling procedures between December 2010 and December 2012. Each fat graft was harvested from the infraumbilical abdomen using Coleman's technique, with 100 to 160ml harvested at each procedure. The patient developed a recurrence of her breast cancer, confirmed by biopsy in May 2013. She underwent right mastectomy and immediate reconstruction with free DIEP flap in July 2013. Preoperative MRA of the abdomen (Fig. 4) demonstrated a single large patent perforator below and right of the umbilicus. Clinical findings correlated with the scan and the above perforator was raised with the flap. There were no abnormal intraoperative findings. The patient had an unremarkable recovery and was discharged 5 days postoperatively. No fat necrosis or wound dehiscence was detected at follow-up clinic appointments (Fig. 5).

Figure 4. Case 2 - MR angiogram demonstrating a single large patent perforator below and right of the umbilicus (arrow).

Figure 5. Case 2 - Appearance 1 week following DIEP flap breast reconstruction.

Timing of surgery

Perforator vessels of the rectus abdominis muscle have potential for re-growth after undermining of the skin and fat of the anterior abdominal wall.

Ribuffo et al² studied the perforator arteries of 10 patients following abdominoplasty using colour duplex scanning. They were found to regain their patency by 3 months, and increase in diameter up to 6 months post-op. However, new vessel calibre never exceeded 40% of preoperative diameter. In the same paper, a cadaveric study of a woman 10 years post-abdominoplasty showed no re-growth of accompanying veins. The authors caution against the use of TRAM flaps in post-abdominoplasty patients.

Hallock and Rice investigated the use of a pedicled TRAM flap after abdominoplasty in a rat model. 13.7% flap viability (Zone I only) was reported when raised 10 months after abdominoplasty.⁸

Emeri et al performed liposuction on two cadavers followed by microangiography of the deep inferior epigastric artery. The perforator vessels from the rectus fascia remained intact after liposuction.⁵ As cadaveric studies do not allow for the physiological response to vascular trauma that occurs in live patients,¹ this should not necessarily be extrapolated to the clinical setting, but our findings suggest that this is probably the case.

Inceoglu et al⁹ studied the effect of liposuction on perforator vessels by Duplex ultrasound. 57.8% of abdominal perforators were not detected at 2 weeks or 3 months post-operatively. However, Salgarello et al showed ‘no significant injury to most perforating vessels’ at 6 months following superficial subdermal liposuction, as detected by colour and pulsed-wave Doppler sonography.¹

Five DIEP flaps after single-episode liposuction were reported by DeFrene et al.⁶ The minimum interval between liposuction and reconstruction was 4 years. Our report demonstrates safe DIEP flap breast reconstruction 16 months following multiple liposuction procedures. Though there remains no agreement on a timeline for vessel recovery prior to safe free tissue transfer without complications, we believe six months should be the minimum interval.

Imaging modality

Several imaging modalities have been used for the assessment of perforators prior to reconstruction.

Methylene blue dye⁴ gives a rapid assessment of the presence of perforators and the soft tissue territory supplied, but it does not identify which perforators are responsible for the perfusion observed. It may be difficult to judge the usefulness of the perforators present if appearance of the dye at the skin is delayed. There is also concern that dye may harm vessels by vasoconstriction secondary to inhibition of nitric oxide.

Duplex ultrasound^1,2,3 allows the evaluation of perforator number, location, diameter and flow velocity. It does not give information on the precise tissue perfusion of a given perforator, which is relevant if there are concerns about smaller branches being injured during liposuction.

CT angiography accurately assesses perforator course, which aids the raising of flaps by reducing the potential for perforator injury.⁷ It also provides information on perforator size and number, allowing the surgeon to pre-select the optimum perforators for a given flap. We prefer magnetic resonance angiography as it provides the benefits of CTA described above without ionising radiation, and with a lower risk of reaction to intravenous contrast medium.