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on the expander/implant confirms appropriate position initiated 4‑6 weeks postoperatively. Permanent smooth,
[4]
and integrity of the alloderm sling [Figure 4]. The round silicone gel implants were exchanged once the
expander/implant is then deflated to allow room for patient’s desired breast volume was met.
the microvascular anastomosis of the internal mammary
vessels to the deep inferior epigastric pedicle. The DIEP RESULTS
flap is then secured in place, the overlying mastectomy
skin is approximated, and a subjective amount of saline Five patients underwent combined DIEP/TE
is infused into the TE/implant. This is all done while reconstruction. The average age was 50 years, and
ensuring that: (1) the alloderm sling is competent; (2) the all patients had early disease, few comorbidities, and
DIEP flap appearance and Doppler signal do not change; were not smokers [Table 1]. Four patients had no prior
and (3) the mastectomy skin appears well perfused. As in reconstruction, one patient had prior bilateral TE
routine breast reconstruction, the patient is then placed placement with postoperative radiation and subsequent
in an upright position, and the appropriate placement infections that led to significant deformities bilaterally
of the DIEP flap and expander/implant with resolution and her desire for secondary reconstruction.
of any volume asymmetries is confirmed. Two 10‑flat
Jackson Pratt drains are placed in each breast: one within Of the 5 immediate DIEP flap/TE patients, four patients
the alloderm breast pocket and the other outside of the underwent bilateral reconstructions, and 1 patient had a
alloderm infero‑laterally. Postoperatively, the patients are stacked DIEP flap with implant placement for a unilateral
placed on DVT prophylaxis until day of discharge and defect [Figure 5]. There were no reoperations, episodes of
antibiotics until the drains are discontinued. As historically venous congestion, hematomas, partial or total flap losses,
described with TRAM/implant procedures, expansion was seromas, infections, or expander/implant leaks [Table 2].
There were no instances of expander/implant extrusion,
migration or palpability. The average final expander size
was 325 mL ± 132.5 mL (range: 200‑400 mL). All patients
have undergone an uneventful expander/implant exchange
procedure, and none has necessitated a revision or fat
grafting procedures to correct asymmetries. All patients
describe being “very satisfied” with their reconstructive
result (score 4) with subjective improvement in volume
and projection of their breasts. Length of follow‑up
ranged from 6 to 18 months [Figure 6].

DISCUSSION

Plastic surgeons are constantly searching for ways to
[1]
optimize techniques and perfect results. Koshima et al.
was the first to improve upon the TRAM flap design by
Figure 4: (A) Dissected and exposed recipient internal mammary artery isolating the abdominal tissue on perforators and sparing
and vein; (B) alloderm sling sutured in place to the rib periostium the muscle. Not surprisingly, the DIEP flap has since
superiorly and inferiorly as well as to the medial edge of the pectoralis. gained widespread popularity and made inroads as the
The subpectoral expander is therefore limited from migrating medially
towards the internal mammary vessels by the alloderm sling gold standard for autologous reconstruction, providing

Table 1: Cohort demographics, comorbid conditions and oncologic characteristics
Age Height Weight BMI Co-morbidities Smoker Preoperative radxn Prior recon Breast cancer stage Bilat recon
(years) (m) (kg)
41 1.54 68.03 28.3 None No No No I Yes
50 1.70 58.51 20.4 None No No No 0 No
55 1.60 58.51 23.4 None No Yes Yes II Yes
49 1.70 71.66 25.1 None No No No I Yes
50 1.65 57.15 20.7 HTN, DM No No No 0 Yes
BMI: Body mass index, DM: Diabetes mellitus, HTN: Hypertension
Table 2: Cohort operative details and complications
Patient Expander size Initial saline infused Hematoma Seroma Injury to flap Infection Asymm Satisfaction score (1-4)
1 350 mL 0 mL No No No No No 4
2 250 mL 150 mL No No No No No 4
3 250 mL 0 mL No No No No No 4
4 250 mL 200 mL No No No No No 4
5 275/400 mL 200/275 mL No No No No No 4

Plast Aesthet Res || Vol 2 || Issue 2 || Mar 13, 2015 65