Abdominal Based Free Flap Breast Reconstruction: Stratifying Complications with Perforator Numbers
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BACKGROUND: Single perforator flaps in breast reconstruction have been reported to have increased fat necrosis. We were motivated to evaluate our experience and the effect of number of perforators on DIEP flap complications and donor site morbidity. METHODS: 199 patients underwent 328 DIEP flaps by two surgeons from 2010 to 2016 at a university hospital. Perforator selection was guided by CT imaging and clinical observation. First, perforator average size was compared among flaps with 1 perforator (n= 110 flaps), 2 perforators (n= 136 flaps), and 3 perforators (n= 82 flaps). Next, rates of fat necrosis, flap failure, and abdominal bulging were analyzed among the same three perforator groups. In addition, rates of postoperative abdominal bulge requiring surgical intervention was compared to the presence of a nerve-preserving type flap harvest. RESULTS: Average perforator size significantly decreased as the number of perforators increased (1 perforator = 2.11mm, 2 perforators = 1.80mm, 3 perforators = 1.65mm, p-value = 0.02 and 0.01 for 1 versus 2 perforator flaps and 1 versus 3 perforator flaps, respectively). However, no significant differences were noted in fat necrosis, flap failure, and abdominal bulging rates across perforator groups. Additionally, flap weights were not significantly different across the three groups (Average: 1 perforator-774 grams, 2 perforators-797 grams, and 3 perforators- 749 grams). Neither perforator number nor nerve preserving techniques were found to result in significant decreases in abdominal bulge rates. CONCLUSIONS: Contrary to other studies, we found that the number of perforators harvested in DIEP flap breast reconstruction was not associated with increase or decrease in flap survival or fat necrosis. This occurrence could be attributed to the surgeons' choosing to proceed with single perforator flaps only when perforator size was adequately large, maintaining consistent blood supply. There was no association among perforator number, utilization of nerve sparing procedures, and abdominal bulge that required subsequent surgical intervention. Despite this, we still cautiously advocate nerve-preserving techniques that may have a subclinical effect.