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a b

a b
Figure 2: Case 2, (a) Patient prior to breast reconstruction with severe
capsular contracture; (b) after DIEP flap procedure. DIEP: Deep inferior
epigastric perforator

a challenge for the surgeon to predict the adequacy
c
of perforators in the future donor site. As noted by
Figure 1: Case 1, patient before (a) and after (b), deep inferior epigastric Wes et al., breast reconstructive in the context of
[21]
perforator procedure with evidence of mild cellulitis surrounding the
flap; (c) patient at 2 years follow‑up after additional nipple reconstructive previous abdominal surgery therefore requires a thorough
produces and extensive weight loss preoperative evaluation to prevent flap morbidity.
Specifically in the context of liposuction, duplex ultrasound
Previous literature has shown conflicting evidence regarding and CT angiography will help identify perforator viability to
the effect of liposuction on donor tissue, specifically, reduce procedural complications. The use of color duplex
perforator vessels. Teimourian and Kroll reported that examination as a preoperative guide is reported to have a
[16]
neurovascular bundles remain intact following conventional true‑positive rate of 96.2% and a positive predictive value
liposuction on examination with subcutaneous endoscopy. of 100% in the hands of an experienced sonographer.
[22]
However, a study by Ozcan et al. demonstrated that flap The use of CT angiography as a preoperative methodology
[17]
necrosis is directly related to the number of suction passes was reinforced by both Bank et al. and Rozen et al.
[23]
[24]
[18]
of a cannula accompanied by a vacuum. İnceoğlu et al. to confirm perforator presence and communication for
reported a 57.8% decrease in the number of perforators in facilitating DIEP flap paddle design in postabdominal
[24]
abdominal subcutaneous tissue 3 months after liposuction procedure patients. Rozen et al. highlighted the
using duplex ultrasound. Despite the reported decrease in benefit of preoperative CT flap design as a method for
[5]
the number of perforators, Ribuffo et al. demonstrated identifying perforators resulted from neovascularization
that perforator arteries regenerate up to 40% of their offering additional possibilities for DIEP harvesting. Other
original diameter after liposuction. This evidence suggests techniques such as flap perfusion mapping may be useful
that the liposuction technique may influence the degree when the surgeon needs to know the integrity of vessels
to which perforator vessels are damaged and the outcome that are too small to image with standard angiographic
[25]
[26]
of the flap. techniques preoperatively. In addition, Masia et al.
described multidetector‑row CT, an imaging modality that
It should be possible to minimize patient complications allows for interpretation of a virtual anatomic dissection
associated with free‑flap breast reconstruction after in three dimensions with very high spatial resolution.
liposuction through modification of the initial liposuction Intraoperative laser angiography using the SPY system
procedure and decreasing trauma to perforators during has been shown to be beneficial for assessing tissue
liposuction. The variability in a number of perforators perfusion during flap elevation. Application of SPY laser
[27]
after liposuction is likely related to factors such as the angiography decreases the incidence skip necrosis in
cannula used, the number of passes, strength of suction postmastectomy reconstruction and the rate of reoperation
and operator force and technique. An ultrasound‑assisted due to of perfusion related complications. Finally,
[28]
liposuction technique described by Zocchi showed less Farid et al. prefer MR angiography to CT angiography
[19]
[8]
damage to neurovascular structures. However, these findings to avoid reliance on intravenous contrast and to reduce
were later opposed by a study which compared conventional patient exposure to radiation. Appropriate application
versus ultrasonic liposuction. Salgarello et al. suggest of these techniques for perforator evaluation including
[2]
[20]
employing a superficial subdermal liposuction technique to CT, ultrasound, or perfusion mapping may improve the
maintain perforator viability. Overall, a refined technique outcome of patients undergoing DIEP after abdominal
or protocol for liposuction in future free flap donor areas liposuction
may improve patient outcome.
There are inherent difficulties in choosing when to use a CONCLUSION
technique to maximize perforator viability. For example,
it is not possible to predict which patients will require We have demonstrated two cases, in addition to the previously
autologous breast reconstruction with a free flap at the reported literature that suggest previous conventional
time of abdominal liposuction. Furthermore, patients liposuction is not an absolute contraindication for free‑flap
may have breast reconstruction with a different surgeon breast reconstruction. Preoperative management of the
than the one who performed the liposuction, creating patient should include thorough evaluation of suitable
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