Clinical Scenarios Using Thoracodorsal and Lateral Thoracic Vessels Versus Internal Mammary Vessels in Bipedicled Deep Inferior Epigastric Perforator Flap Breast Reconstruction: A Comparative Study

Chia-Fang Chen; David Chon-Fok Cheong; Wen-Ling Kuo; Chi-Chang Yu; Hsu-Huan Chou; Shin-Cheh Chen; Jung-Ju Huang

doi:10.1055/a-2717-4996

Journal of Reconstructive Microsurgery, Inhaltsverzeichnis

J Reconstr Microsurg
DOI: 10.1055/a-2717-4996

Original Article

Clinical Scenarios Using Thoracodorsal and Lateral Thoracic Vessels Versus Internal Mammary Vessels in Bipedicled Deep Inferior Epigastric Perforator Flap Breast Reconstruction: A Comparative Study

Authors

Chia-Fang Chen

¹Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan

²College of Medicine, Chang Gung University, Taoyuan, Taiwan

³Breast Cancer Center, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan
David Chon-Fok Cheong

¹Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan

²College of Medicine, Chang Gung University, Taoyuan, Taiwan

³Breast Cancer Center, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan
Wen-Ling Kuo

³Breast Cancer Center, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan

⁴Division of Breast Surgery, Department of Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan

⁵School of Medicine, National Tsing Hua University, Hsinchu, Taiwan
Chi-Chang Yu

³Breast Cancer Center, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan

⁴Division of Breast Surgery, Department of Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan
Hsu-Huan Chou

³Breast Cancer Center, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan

⁴Division of Breast Surgery, Department of Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan
Shin-Cheh Chen

³Breast Cancer Center, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan

⁴Division of Breast Surgery, Department of Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan
Jung-Ju Huang

¹Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan

²College of Medicine, Chang Gung University, Taoyuan, Taiwan

³Breast Cancer Center, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan

Abstract

Background

Autologous breast reconstruction using the bipedicled deep inferior epigastric perforator (DIEP) flap poses unique challenges in Asian patients with a low BMI and limited donor volume. While internal mammary vessels (IMA/Vs) remain the standard recipient site, the rise of minimally invasive mastectomy has limited access to IMA/Vs. This study compared the results of thoracodorsal and lateral thoracic vessels (lateral-based) versus IMA/Vs (medial-based) in bipedicled DIEP flap breast reconstruction.

Methods

A retrospective review was conducted on 62 patients who underwent bipedicled DIEP flap reconstruction between 2018 and 2023 by a single senior surgeon. Patients were stratified by incision placement and recipient vessel choice into medial- and lateral-based groups. Clinical outcomes, complication rates, and long-term aesthetic results were analyzed.

Results

Despite a higher re-exploration rate in the lateral-based group (12.5% versus 4.5%; p = 0.298), flap survival was comparable between the groups. Fat necrosis rates were lower in flaps without re-exploration (5.4%) and increased significantly following compromised perfusion (33.3%). The lateral-based group achieved superior aesthetic outcomes in breast shape (p = 0.043) and scar visibility (p < 0.001), with a reduced need for secondary fat grafting. Dual vascular sources provided more reliable perfusion and improved long-term fat survival, although further validation with perfusion imaging is warranted.

Conclusion

The lateral-based approach, despite technical challenges, is a viable alternative to the medial-based method in certain patients, offering reliable perfusion and superior aesthetic outcomes with fewer revisions. An algorithmic approach to recipient vessel selection can optimize outcomes of bipedicled DIEP flap reconstruction.

Keywords

mastectomy - device-assisted mastectomy - autologous breast reconstruction - bipedicled DIEP flap - internal mammary vessels - thoracodorsal vessels - lateral thoracic vessels

Volltext

Referenzen

References
1 Cancer Registry Annual Report, Republic of China, 1995. Taipei, Taiwan: Department of Health, Executive Yuan; 1997
2 Cancer Registry Annual Report, Taiwan, 2020. Taipei, Taiwan: Ministry of Health and Welfare, Taiwan; 2022
3 Survival Analysis of Cancer Patients in Taiwan. 2017–2021. Taipei, Taiwan: Taiwan Cancer Registry; 2023
4 Zehra S, Doyle F, Barry M, Walsh S, Kell MR. Health-related quality of life following breast reconstruction compared to total mastectomy and breast-conserving surgery among breast cancer survivors: a systematic review and meta-analysis. Breast Cancer 2020; 27 (04) 534-566
5 Li Y, Guo J, Sui Y, Chen B, Li D, Jiang J. Quality of life in patients with breast cancer following breast conservation surgery: a systematic review and meta-analysis. J Healthc Eng 2022; 2022: 3877984
6 Fanakidou I, Zyga S, Alikari V, Tsironi M, Stathoulis J, Theofilou P. Mental health, loneliness, and illness perception outcomes in quality of life among young breast cancer patients after mastectomy: the role of breast reconstruction. Qual Life Res 2018; 27 (02) 539-543
7 Fortunato L, Loreti A, Cortese G. et al. Regret and quality of life after mastectomy with or without reconstruction. Clin Breast Cancer 2021; 21 (03) 162-169
8 Chao AH. Safe and efficient implant-based breast reconstruction. Plast Reconstr Surg Glob Open 2020; 8 (09) e3134
9 Garza III R, Ochoa O, Chrysopoulo M. Post-mastectomy breast reconstruction with autologous tissue: current methods and techniques. Plast Reconstr Surg Glob Open 2021; 9 (02) e3433
10 Rose J, Puckett Y. Breast Reconstruction Free Flaps. In:, StatPearls. Treasure Island (FL): 2025
11 Hartrampf CR, Scheflan M, Black PW. Breast reconstruction with a transverse abdominal island flap. Plast Reconstr Surg 1982; 69 (02) 216-225
12 Holm C, Mayr M, Höfter E, Ninkovic M. Perfusion zones of the DIEP flap revisited: a clinical study. Plast Reconstr Surg 2006; 117 (01) 37-43
13 Hernandez Rosa J, Sherif RD, Torina PJ, Harmaty MA. Use of both antegrade and retrograde internal mammary vessels in the bipedicled deep inferior epigastric perforator flap for unilateral breast reconstruction. J Plast Reconstr Aesthet Surg 2017; 70 (01) 47-53
14 Tomioka YK, Uda H, Yoshimura K, Sunaga A, Kamochi H, Sugawara Y. Studying the blood pressures of antegrade and retrograde internal mammary vessels: do they really work as recipient vessels?. J Plast Reconstr Aesthet Surg 2017; 70 (10) 1391-1396
15 Ryu JM, Kim JY, Choi HJ. et al. Robot-assisted nipple-sparing mastectomy with immediate breast reconstruction: an initial experience of the Korea Robot-endoscopy Minimal Access Breast Surgery Study Group (KoREa-BSG). Ann Surg 2022; 275 (05) 985-991
16 Kim JH, Kim YS, Moon SH, Jun YJ, Rhie JW, Oh DY. Diametric comparison between the thoracodorsal vessel and deep inferior epigastric vessel in breast reconstruction. BioMed Res Int 2020; 2020: 6352939
17 Guay NA. The thoracodorsal vessels are advantageous, reliable, and safe recipient vessels for free abdominal flap breast reconstruction. Ann Plast Surg 2012; 68 (05) 539-541
18 Huang JJ, Chuang EY, Cheong DC. et al. Robotic-assisted nipple-sparing mastectomy followed by immediate microsurgical free flap reconstruction: feasibility and aesthetic results—case series. Int J Surg 2021; 95: 106143
19 Wang C, Roy N, Montalmant KE. et al. Deep inferior epigastric perforator flap with implant placement has a favorable complication profile compared with implant-only or flap-only reconstruction. J Reconstr Microsurg 2025; 41 (07) 631-640
20 Seth AK, Koolen PGL, Sultan SM, Lee BT, Erhard HA, Greenspun DT. Unilateral autologous breast reconstruction with bi-pedicled, conjoined deep inferior epigastric perforator flaps. J Reconstr Microsurg 2019; 35 (02) 145-155
21 Sergesketter AR, Shammas RL, Taskindoust M. et al. A comparison of patient-reported outcomes in bipedicled total abdominal versus unipedicled hemiabdominal free flaps for unilateral breast reconstruction. J Reconstr Microsurg 2021; 37 (09) 753-763
22 Sultan SM, Seth AK, Lamelas AM, Greenspun DT, Erhard HA. Bipedicle-conjoined deep inferior epigastric perforator flaps for unilateral breast reconstruction in overweight and obese patients: do the benefits outweigh the risks?. J Reconstr Microsurg 2020; 36 (05) 346-352
23 Kim H, Lee SB, Nam SJ. et al. Survival of breast-conserving surgery plus radiotherapy versus total mastectomy in early breast cancer. Ann Surg Oncol 2021; 28 (09) 5039-5047
24 Sun ZH, Chen C, Kuang XW, Song JL, Sun SR, Wang WX. Breast surgery for young women with early-stage breast cancer: mastectomy or breast-conserving therapy?. Medicine (Baltimore) 2021; 100 (18) e25880
25 Liew B, Southall C, Kanapathy M, Nikkhah D. Does post-mastectomy radiation therapy worsen outcomes in immediate autologous breast flap reconstruction? A systematic review and meta-analysis. J Plast Reconstr Aesthet Surg 2021; 74 (12) 3260-3280
26 O'Connell RL, Di Micco R, Khabra K. et al. Comparison of immediate versus delayed DIEP flap reconstruction in women who require postmastectomy radiotherapy. Plast Reconstr Surg 2018; 142 (03) 594-605
27 Cocquyt VF, Blondeel PN, Depypere HT. et al. Better cosmetic results and comparable quality of life after skin-sparing mastectomy and immediate autologous breast reconstruction compared to breast conservative treatment. Br J Plast Surg 2003; 56 (05) 462-470
28 Selber JC. Robotic nipple-sparing mastectomy: the next step in the evolution of minimally invasive breast surgery. Ann Surg Oncol 2019; 26 (01) 10-11
29 Harashina T, Imai T, Nakajima H, Fujino T. Breast reconstruction with microsurgical free composite tissue transplantation. Br J Plast Surg 1980; 33 (01) 30-37
30 Hefel L, Schwabegger A, Ninković M. et al. Internal mammary vessels: anatomical and clinical considerations. Br J Plast Surg 1995; 48 (08) 527-532
31 Nahabedian M. The internal mammary artery and vein as recipient vessels for microvascular breast reconstruction. Ann Plast Surg 2012; 68 (05) 537-538
32 Lorenzetti F, Kuokkanen H, von Smitten K, Asko-Seljavaara S. Intraoperative evaluation of blood flow in the internal mammary or thoracodorsal artery as a recipient vessel for a free TRAM flap. Ann Plast Surg 2001; 46 (06) 590-593
33 Culliford IV AT, Spector J, Blank A, Karp NS, Kasabian A, Levine JP. The fate of lower extremities with failed free flaps: a single institution's experience over 25 years. Ann Plast Surg 2007; 59 (01) 18-21 , discussion 21–22
34 Moran SL, Nava G, Behnam AB, Serletti JM. An outcome analysis comparing the thoracodorsal and internal mammary vessels as recipient sites for microvascular breast reconstruction: a prospective study of 100 patients. Plast Reconstr Surg 2003; 111 (06) 1876-1882
35 Parikh JA, Bombardelli J, Doval A, Spiegel AJ. Strategic approaches to intraflap anastomosis: navigating conjoined DIEP flap reconstruction—a comprehensive roadmap. Plast Reconstr Surg Glob Open 2024; 12 (02) e5627
36 Finlay B, Kollias V, Hall KA. et al. Long-term outcomes of breast reconstruction and the need for revision surgery. ANZ J Surg 2021; 91 (09) 1751-1758
37 Cao Z, Cao J, Pang X, Du W, Wu P. A comparative study for the rate of adverse outcomes in unilateral and bilateral abdominal flap breast reconstruction: a meta-analysis. Medicine (Baltimore) 2020; 99 (37) e22096
38 Nelissen SH, Krijnen NA, Tsehaie J. et al. Bulging after DIEP breast reconstruction: new insights concerning rectus diastasis and medial perforator harvest. Plast Reconstr Surg Glob Open 2023; 11 (03) e4840

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