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to limit potential injury to the flap during expansion). a relatively easy dissection, it provides a rather small
The subpectoral placement is the standard technique skin paddle and thin, fat pad, which limits its utility
for expander reconstruction, leading to fewer capsular for reconstruction of small to medium‑sized breasts.
contractures and better concealing the outline of the Furthermore, atrophy of the gracilis muscle may cause
expander. [1,2,4,8] Initially, saline was not immediately infused secondary volume and contour deformities, requiring
into the expander for fear that it could indirectly injure additional corrections. [10,11] The PAP flap has a relatively
the flap through pressure. However, in our subsequent long vascular pedicle and the scar may be hidden in
cases various amounts of saline were infused into the the lower buttock crease. However, there may be scar
expander and changes in the implantable Doppler, flap, tenderness causing problems with sitting, visibility of the
and overlying mastectomy skin was directly visualized. scar in swimwear or underwear, and asymmetrical donor
If any of these variables were negatively affected by the site with unilateral breast reconstruction. Fat grafting is
[12]
expansion, the volume was decreased. In our cohort, an option for increasing volume, but it requires multiple
there were no reoperations, partial or total flap losses, procedures and often does not allow for large volume
hematomas, infections, implant failures, or asymmetries. augmentation in excess of 150 mL or more. Although
In contrast to previous reports, our cohort demonstrated this is certainly an option for revision and touch ups, the
no seromas in relation to the initial expansion of the authors routinely do not use large volume fat grafting to
[3]
expander at the time of surgery. We do, however, place augment the volume of DIEP flap reconstruction.
drains within the expander pocket and continue them This cohort has the limitations inherent to any small
until the output is < 30 mL for 24 h. Furthermore, the cohort and retrospective review, which include the
cohort described is the initial experiences with the difficulties in making generalizations from a small
described technique, and thus is currently too small to sample size. Despite the potential benefits of combined
make translatable conclusions.
DIEP/expander reconstruction in patients desiring larger
Our data supports the proven safety of combined TRAM breasts or with insufficient abdominal tissue, women
and DIEP/implant procedures as well as the excellent who smoke or have significant co‑morbidities may not be
aesthetic results achieved with this procedure. [1,2,4,8] appropriate candidates for this technique.
Furthermore, there is evidence that combining an implant In this retrospective review, we demonstrate that combined
with autologous tissue appears to reduce implant related DIEP/expander reconstruction is safe and provides excellent
complications in previously irradiated breasts. If a patient long‑term aesthetic results. We report our experience to
[6]
has a unilateral defect, stacking two DIEP flaps on top of further support the notion that combined DIEP/implant
one another can often provide sufficient tissue to recreate procedures can have superior aesthetic results when
a single breast. However, in cases where the patient compared to many of the alternative procedures in this
desires larger breasts and the contralateral breast needs select group of patients. [2,5,6] In addition, we describe
augmentation [Patient 4, Table 2 and Figure 4], combining a technique that may assist surgeons in preventing
a stacked DIEP flap with an expander/implant is an option. any inadvertent injury to the pedicle when performing
This technique achieves the volume and projection the simultaneous DIEP flap/expander reconstruction
patient desires by utilizing an implant, and gives a natural and using the IMA/IMV as the recipient vessels. The
feel and appearance by utilizing an overlying DIEP flap. alloderm technique may provide plastic surgeons with
As suggested by Figus et al., an implant/expander can be the confidence to offer patients this technique as an
[3]
combined with a DIEP flap to address preoperative breast alternative to traditional LD/implant techniques. This
asymmetries. In our cohort, one patient demonstrated technique offers the ability to use an expander in women
these asymmetries [Patient 5, Table 2], and a 275 mL whose overall breast size is not yet finalized and who soft
expander was placed in one side and a 400 mL expander tissue envelope will not support a sizeable implant.
in the other to provide a more symmetric appearance.
A noted alternative to simultaneous augmentation with
DIEP flaps is to address any asymmetries is fat grafting. REFERENCES
However, the advantage of using an implant is to correct
the asymmetry immediately and eliminate the need for 1. Koshima I, Moriguchi T, Soeda S, Tanaka H, Umeda N. Free thin paraumbilical
perforator‑based flaps. Ann Plast Surg 1992;29:12‑7.
multiple revisional surgeries. 2. Kronowitz SJ, Robb GL, Youssef A, Reece G, Chang SH, Koutz CA, Ng RL,
Lipa JE, Miller MJ. Optimizing autologous breast reconstruction in thin
Additional reconstructive techniques being used in patients. Plast Reconstr Surg 2003;112:1768‑78.
patients with inadequate abdominal tissue include the 3. Figus A, Canu V, Iwuagwu FC, Ramakrishnan V. DIEP flap with implant: a
superior gluteal artery perforator (SGAP) flap, transverse further option in optimising breast reconstruction. J Plast Reconstr Aesthet
upper gracilis (TUG) flap or the profunda femoris artery Surg 2009;62:1118‑26.
perforator (PAP) flap. These techniques, however, tend 4. Serletti JM, Moran SL. The combined use of the TRAM and expanders/implants
in breast reconstruction. Ann Plast Surg 1998;40:510‑4.
to be more complex and time intensive. The dissection 5. Tadiparthi S, Alrawi M, Collis N. Two‑stage delayed breast reconstruction with
of the muscle for the SGAP is technically difficult and an expander and free abdominal tissue transfer: outcomes of 65 consecutive
possesses a relatively short vascular pedicle. There is cases by a single surgeon. J Plast Reconstr Aesthet Surg 2011;64:1608‑12.
also the possibility for contour deformity and asymmetry 6. Roehl KR, Baumann DP, Chevray PM, Chang DW. Evaluation of outcomes in
breast reconstructions combining lower abdominal free flaps and permanent
of the buttocks, particularly in the case of unilateral implants. Plast Reconstr Surg 2010;126:349‑57.
breast reconstruction. Although the TUG flap involves 7. Chia HL, Breitenfeldt N, Canal AC, Malata CM. Implant augmentation
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Plast Aesthet Res || Vol 2 || Issue 2 || Mar 13, 2015 67