Multiple pregnancies following deep inferior epigastric perforator (DIEP) flap breast reconstruction

Journal of Plastic, Reconstructive & Aesthetic Surgery (2013) 66, 434e436

CASE REPORT

Multiple pregnancies following deep inferiorepigastric perforator (DIEP) flap breastreconstruction

Ketan M. Patel, Deniz Basci, Maurice Y. Nahabedian*

Georgetown University Hospital, Department of Plastic Surgery, 3800 Reservoir Rd. NW, Washington DC 20007, USA

Received 23 May 2012; accepted 17 July 2012

KEYWORDSPregnancy;DIEP flap;Breast reconstruction

* Corresponding author. Tel.: þ1 207180.

E-mail addresses: DrNahabediancom (M.Y. Nahabedian).

1748-6815/$-seefrontmatterª2012Brihttp://dx.doi.org/10.1016/j.bjps.2012.0

Summary Pregnancy following abdominal flap-based breast reconstruction may cause stressto the abdominal wall. These changes may result in weakness and hernia or bulge. We presenttwo patients who previously underwent unilateral deep inferior epigastric perforator (DIEP)flap breast reconstruction and became pregnant twice. Both patients maintained abdominalcontour without bulges or hernias. Subjectively, patients reported minor changes to abdominalstrength. Therefore, these two patients had minimal abdominal morbidity following pregnancyafter unilateral DIEP flap reconstruction.ª 2012 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published byElsevier Ltd. All rights reserved.

Breast cancer awareness and detection has drasticallyimproved over the last few decades. Earlier detection andimproved reconstructive techniques have allowed womento achieve excellent aesthetic results with limited donor-site morbidity. In addition, earlier detection and increas-ingly aggressive treatment strategies have combined toresult in younger patients seeking treatment. This cohort ofpatients electing for autologous reconstruction usingabdominal flaps may have late donor-site morbidity asmany of these women are of child-bearing age with possible

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tishAssociationofPlastic,Reconstruc7.012

future pregnancies. Previous reports have highlighted theimpact of pregnancy on patients who have had deep infe-rior epigastric perforator/transverse rectus abdominusmyocutaneous (DIEP/TRAM) flaps.1e4 One study has high-lighted the impact of multiple pregnancies in this patientpopulation, reporting a sole patient who had a double-pedicled TRAM flap with mesh reinforcement of theabdominal wall.4 We present two patients who underwentunilateral DIEP flap breast reconstruction and later becamepregnant twice following breast reconstruction.

Patient 1

A 29-year-old female who had previously undergone breastconservation therapy elected to undergo completion

tiveandAestheticSurgeons.PublishedbyElsevierLtd.All rightsreserved.

Multiple pregnancies following deep inferior epigastric perforator 435

mastectomy and unilateral breast reconstruction. She wasotherwise healthy with a body mass index (BMI) of 32.4 andunderwent unilateral single-medial perforator DIEP flapreconstruction. Minimal muscle dissection occurred toprevent late muscle injury and fibrosis. In addition, iden-tified nerves to the rectus muscle were preserved. Theanterior rectus sheath was closed primarily with a two-layered permanent suture repair. The patient had anuneventful postoperative period. She underwent Caesareansection delivery 19 months following reconstruction due toprolonged delivery. She subsequently had a second child 14months following the first pregnancy. She did not developany postoperative bulge/hernia. In addition, the patientreported slight weakness of abdominal strength as relatedto increased levels of activity, but said there were nolimitations in her activities of daily living at a follow-upperiod of 14 months following her last pregnancy.

Patient 2

A 36-year-old female underwent unilateral immediatebreast reconstruction with a single-medial perforator DIEPflap. She was otherwise healthy with a BMI of 24.4. Minimalmuscle dissection occurred with identified motor nerves tothe rectus muscle being preserved. The anterior rectussheath was repaired with a two-layered closure withpermanent sutures. She had an uneventful hospital course(Figure 1). She later became pregnant prior to finishingnipple reconstruction and delivered her first child 12months after breast reconstruction. She underwent anuneventful full-term vaginal pregnancy. Following the firstpregnancy, the patient returned for planning of the finalstages of breast reconstruction and was noted to be 3months pregnant (Figure 2). She later underwent anuneventful second full-term vaginal pregnancy approxi-mately 2 years following the first pregnancy. She did not

Figure 1 Patient 2 following unilateral DIEP flap recon-struction. The patient had an uneventful hospital course.

develop an abdominal bulge/hernia following her preg-nancies. Also, the patient reported similar abdominalstrength with no limitations at a follow-up period of 8months following her last pregnancy.

Discussion

Determining the impact of pregnancy on the functionalityof the abdominal wall following abdominal flap-basedbreast reconstruction continues to be debated. Most liter-ature related to this subject pertains to patients who havehad TRAM flap reconstruction with subsequent preg-nancy.4e7 Chen et al. evaluated six patients who becamepregnant following TRAM flap reconstruction. In theirseries, one patient had multiple pregnancies followinga bilateral pedicle TRAM flap reconstruction.4 Two casereports have provided insight into the impact of DIEP flapreconstruction in this cohort. Bhat et al. found thatsuccessful pregnancy occurred 3 months following single-perforator unilateral DIEP flap reconstruction.2 Similarly,Ong et al. described one patient who had a successfulpregnancy following DIEP flap reconstruction.8

We present the first report of multiple pregnanciesfollowing DIEP flap reconstruction. Similar to Bhat et al.,early pregnancy following DIEP flap reconstruction ispossible with little late consequence to the function of theabdominal wall, as seen also in our patient (patient 2) whobecame pregnant approximately 3 months following breastreconstruction. Both patients did not exhibit symptoms orsigns of abdominal bulge/hernia following both pregnan-cies. Although one patient in our series reported weaknesswith increased levels of fitness, overall abdominal wallfunctionality remained similar to subjective pre-reconstruction strength.

These results highlight the safety and strength ofprimary repair of the anterior abdominal wall following

Figure 2 Patient 2 was found to be 3 months pregnant duringa clinic visit.

436 K.M. Patel et al.

DIEP flap reconstruction. Despite being stressed by twopregnancies, the anterior abdominal wall of both patientsmaintained strength without hernia or bulge formation.

Conflict of interest

Dr. Nahabedian is a member of the speakers bureau forLifecell Corp., Branchburg, New Jersey. All other authorshave no conflicts of interest or financial disclosures. Nofunding was utilized for the preparation of this manuscript.

References

1. Carramaschi FR, Ramos ML, Pinotti JA, et al. Pregnancyfollowing breast reconstruction with TRAM flaps. Breast J 1998;4:258e60.

2. Bhat B, Akhtar A, Akali A. Pregnancy in the early stagesfollowing DIEP flap breast reconstructionea review and casereport. J Plast Reconstr Aesthetic Surg 2010;63:e782e4.

3. Collin C, Coady C. Is pregnancy contraindicated following freeTRAM breast reconstruction? J Plast Reconstr Aesthetic Surg2006;59:556e9.

4. Chen L, Hartrampf CR, Bennett GK. Successful pregnanciesfollowing TRAM flap surgery. Plast Reconstr Surg 1993;91:69e71.

5. Zeligson G, Hadar A, Koretz M, et al. Uneventful pregnancy anddelivery after TRAM flap reconstruction following bilateralmastectomies. Isr Med Assoc J 2011;13:381e3.

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7. Parodi PC, Osti M, Longhi P, et al. Pregnancy and tram-flapbreast reconstruction after mastectomy: a case report. ScandJ Plast Reconstr Surg Hand Surg 2001;35:211e5.

8. Ong WC, Lim J, Lim TC. Successful pregnancy after breastreconstruction with the deep inferior epigastric artery perfo-rator flap. Plast Reconstr Surg 2004;114:1968e70.