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Figure 5: Right stacked deep inferior epigastric perforator (DIEP) flap
with immediate subpectoral 250 mL expander and nipple reconstruction.
Left breast augmentation with subpectoral 250 mL gel implant. Three
months postoperative

both a lasting result and breasts that appear and feel
natural.
Figure 6: One‑year postoperative: bilateral deep inferior epigastric
However, not all women who desire autologous perforator (DIEP) with immediate expanders, subsequent expander/400 mL
reconstruction have sufficient abdominal tissue to recreate gel implant exchange. Delayed nipple and areola reconstruction
an aesthetic appearing breast. Alternative donor sites
for autologous reconstruction include the gluteal region, implant placement. Fourteen patients were selected as
posterior thigh, and medial thigh, however, these sites candidates for DIEP/implant reconstruction based on
generally contribute even less tissue than the abdomen. similar criteria to that previously reported in the literature;
Historically, the standard procedure for thin women these patients were then prospectively followed. Ten
desiring autologous reconstruction was a combined LD patients had implants placed subpectorally at the time
flap/implant breast reconstruction. Kronowitz et al. of the DIEP flap, and 4 patients had the implants placed
[2]
recently demonstrated that a superior alternative to the in a delayed fashion directly under the DIEP flap. Their
LD flap/implant procedure in this patient population is a preferred vessel for anastomosis was the thoracodorsal
combined TRAM/implant procedure. Eighteen TRAM/implant artery and vein. They did not experience any total flap
patients demonstrated a higher aesthetic score when losses or episodes of microvascular thrombosis, however,
compared to the LD/implant group by both the patients they did experience an immediate postoperative infection
and a panel of blinded judges. The overall impression by and hematoma that led to partial flap loss and removal
the blinded judges was that the TRAM flap more accurately of the implant. In addition, they describe an accidental
“recreated the breast with the implant contributing less transection of the internal mammary vessels while placing
to the overall shape” when compared with the LD/implant a delayed implant directly beneath the flap. The aesthetic
[4]
group. Serletti and Moran corroborated these findings by results were analyzed and revealed “very satisfied” and
suggesting that the subcutaneous tissue of the TRAM flap “excellent” outcomes. [3]
more accurately resembles native breast tissue, and unlike
the LD, will not atrophy over time. In fact, any fluctuations Commentary in response to this data argued against
in weight will result in volume changes in the TRAM flaps. placement of immediate implants or expanders with
DIEP flaps for concerns that the implant would either
In addition to superior aesthetic results, the TRAM/implant directly or indirectly compromise the vascularity of the
group experienced fewer donor site complications when flap. This concern for injury to the pedicle, whether
[7]
analyzed against the LD/implant group. The scar from immediately or during the expansion, is the basis behind
[2]
an LD flap tends to widen over time, and while it can be the development of our alloderm sling technique. We
concealed behind a bra, the unilateral contour deformity propose that this technique can prevent potential injury
[1]
of missing the LD muscle can be apparent. On the other to the pedicle whether intraoperatively, in a reoperation
hand, the TRAM or DIEP flap donor site scar does not or any delayed procedures. While total flap loss and
tend to widen over time, has no contour deformity, and microvascular thrombosis events have yet to be described
can be easily concealed with most under‑garments. in the literature with combined TRAM/implant procedures,

While TRAM/implant procedures offer optimal aesthetic we believe that the alloderm sling technique acts as a
results when compared to standard techniques such as safety net to prevent the subpectoral implant/expander
LD/implant, it is technically more challenging. Furthermore, from injuring the pedicle. Clearly, this is less of a concern
concern lies in potentially injuring the TRAM flap when if the preferred recipient vessel is to the thoracodorsal
[3]
combined with implant placement. However, multiple artery and vein, but the alloderm technique may have
authors have demonstrated that in experienced hands, prevented the reported transection of the inferior
TRAM flap reconstruction can be combined with implant mesenteric artery/inferior mesenteric vein (IMA/IMV).
placement without any occurrences of microvascular In our cohort, patients desired larger breasts than the
thrombosis or flap failure. [5,6]
overlying skin envelope could maintain and therefore
Figus et al. was the first to describe successfully we chose to place smooth, round subpectoral expanders
[3]
combining DIEP flap reconstruction with immediate with an external port (the external port was chosen
66 Plast Aesthet Res || Vol 2 || Issue 2 || Mar 13, 2015