Successful DIEP Flap for Breast Reconstruction in a Patient with Prior Abdominoplasty

Sir:FigureWe read with interest the case report by Broyles et al., in which the authors describe a successful deep inferior epigastric artery perforator flap in a patient with a history of abdominoplasty.1 The authors describe this being the first such case, although this was incorrect, with our group reporting a similar case in this Journal earlier this year.2 There are several key differences that warrant discussion, as careful case selection and the role of preoperative imaging are paramount in achieving successful outcomes in abdominal perforator flap harvest after abdominoplasty. In the case report by Broyles et al., the authors describe a “history” of abdominoplasty in their patient, but it is unclear whether the authors performed or had details of that prior operation or not. We wonder whether this was a full abdominoplasty, with wide undermining and umbilical transposition. If this was the case, how could a periumbilical deep inferior epigastric artery perforator still be present for use in a perforator flap? In a standard abdominoplasty, all central deep inferior epigastric artery and deep superior epigastric artery perforators are divided, and only peripheral perforators remain. These may variably be lateral row deep inferior epigastric artery or intercostal artery perforators. Only in a limited abdominoplasty by means of an infraumbilical wedge lipectomy without umbilical transposition would periumbilical perforators be expected to remain intact. In our previous report, our case followed a full abdominoplasty; however, limited undermining of the upper flap had been undertaken, leaving several lateral row deep inferior epigastric artery perforators immediately above the umbilicus intact.2 These were identified on imaging preoperatively and successfully used in performing a deep inferior epigastric artery perforator flap (Fig. 1). Although our report may have been the first reported case for deep inferior epigastric artery perforator flaps in this setting, we should note that several case reports have described successful transverse rectus abdominis myocutaneous flap transfer after abdominoplasty.3,4Fig. 1: Computed tomographic angiograms of the abdominal vasculature in a 50-year-old woman who had undergone previous abdominoplasty. Although there were no infraumbilical perforators, several large supraumbilical perforators were present, with a large 2-mm right perforator (blue arrow) selected (above and center). The perforators were shown to arise from the deep inferior epigastric arteries (white arrows, below).With few such cases reported, it remains important to focus on reliable flap anatomy, and the use of preoperative imaging is certainly a modern technique that can facilitate this. Such imaging can highlight the preserved vasculature and can guide an individualized approach to perforator flap options. Warren M. Rozen, P.G.Dip.Surg.Anat., M.D., Ph.D. Rafael Acosta, M.D. Department of Anatomy and Neurosciences University of Melbourne Parkville, Victoria, Australia DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication.