Autogenous breast reconstruction with the deep inferior

epigastric perforator flap

James E. Craigie, MDa,*, Robert J. Allen, MDb, Frank J. DellaCroce, MDb,Scott K. Sullivan, MDb

aEast Cooper Plastic Surgery, 1300 Hospital Drive, Suite 120, Mt. Pleasant, SC 29464, USAbDivision of Plastic Surgery, LSU Health Sciences Center, 4429 Clara Street, Suite 440, New Orleans, LA 70115, USA

The perfect method for breast reconstruction

would be safe, reliable, reproducible, applicable to

all patients, and have no donor site morbidity. The

ideal reconstructed breast would provide symmetric,

permanent, and natural results. The pursuit of these

goals has fueled the development and refinement of

autogenous methods of breast reconstruction. In

1976, Fugino et al [1] described the gluteus maximus

myocutaneous flap for breast reconstruction. This

was followed in 1979 by Holmstrom’s [2] use of

the rectus abdominus myocutaneous free flap, and in

the early 1980s, Hartrampf et al [3,4] popularized the

pedicled transverse rectus abdominus flap (TRAM).

The TRAM flap remains the most popular method

of autogenous reconstruction. This popularity is due to

the relative ease with which the procedure is per-

formed and the fact that no microsurgical expertise is

required. Proponents also argue that the pedicled

TRAM is quicker to perform, and, thus, saves oper-

ative time and expense; this has not been borne out in

the literature [4]. The pedicled TRAMhas proven to be

a basically reliable method of reconstruction but the

rate of partial flap necrosis may approach 25% [5].

This can be a problemwhen open wounds cause delays

in chemotherapeutic protocols, and, later, when the

differentiation of fat necrosis from a recurrent tumor is

required. The high rate of partial flap necrosis is the

result of a basic anatomic problem with the flap, which

requires reversal of flow through intramuscular choke

vessels into the inferior vasculature. This, combined

with folding and tunneling of the pedicle at its pivot

point, can compromise vascular exchange within the

flap. Tunneling may also affect the medial breast

contour [6]. The free TRAM flap has been used in an

effort to increase flap perfusion but it suffers from the

same limitation of rectus muscle sacrifice. When

patients with rectus sacrifice are compared with those

in which it is preserved, the importance of this con-

sideration is clear.

The deep inferior epigastric arttery perforator

(DIEP) flap for breast reconstruction was innovated

to improve the donor site morbidity that is associated

with the TRAM flap [7]. Patients who are recon-

structed with the DIEP flap experience substantially

less postoperative pain than those who are subjected

to muscle sacrifice (TRAM) [8]. Muscle sacrifice in

pedicle flaps is also responsible for abdominal asym-

metries, hernias, pain, and impaired ability to perform

daily, occupational, and sporting activities. Kroll et al

[9] and Mizgala et al [10] reported that abdominal

wall morbidity was significant and proportional to the

amount of muscle that was removed after TRAM flap

breast reconstruction. The ‘‘muscle sparing’’ free

TRAM is considered less morbid to the abdominal

wall. Some studies indicated, however, that the integ-

rity of the remaining rectus muscle is lost if a small

portion is removed with the flap [11–13]. Weakness

and atrophy of the remaining muscle occur when the

insertion is sacrificed and the quality of the abdom-

inal wall after the free TRAM has been described as

comparable to a pedicle TRAM donor site [14].

0094-1298/03/$ – see front matter D 2003 Elsevier Inc. All rights reserved.

doi:10.1016/S0094-1298(03)00037-3

* Corresponding author.

E-mail address: drcraigie@ecplasticsurgery.com

(J.E. Craigie).

Clin Plastic Surg 30 (2003) 359–369

The inherent advantage of muscle preservation

depends on maintaining the biomechanical stability

and balance of the trunk musculature. The rectus

abdominus is a keystone in the body’s ‘‘powerhouse’’

that enables balanced movement, heavy lifting, and

upright work against external resistance while main-

taining posture and healthy alignment of the spine.

This important point becomes apparent when one

considers the three physiologic types of muscle

activity and how they relate to the role of the rectus

abdominus in abdominal wall function. Isometric

static tension and eccentric lengthening are the two

most important physiologic activities of the rectus

abdominus and directly affect physical capacity. The

integrity of these components maintains biomechan-

ical stability and was shown to be intact after DIEP

flaps; the integrity is significantly impaired when

even a portion of the muscle is removed during free

TRAM flaps [15,16]. The third physiologic muscle

activity, which occurs during a sit-up, is less impor-

tant clinically and involves muscle shortening during

concentric muscle contraction. If concentric contrac-

tion has been weakened secondary to intramuscular

scar formation, then the intact internal oblique

muscles can easily compensate and minimize the

clinical impact. Closure of a defect in the rectus

fascia, however, causes a shift in the contralateral

rectus muscle toward the midline and alters the

mechanical advantage of the internal oblique

muscles. Therefore, the inherent donor site advantage

of the DIEP flap over other flaps that contain even a

small portion of muscle, is related to maintaining the

most important components of muscle activity and

avoiding the additional distortion of the abdominal

wall that occurs when a muscle and fascia defect must

be repaired. Minimizing the impairment of the

abdominal wall results in lower rates of donor site

asymmetries, donor site pain, back pain, hernias,

weakness, and functional impairments. These advan-

tages are exponentially accentuated when bilateral

reconstructions are performed.

The efforts to minimize donor site morbidity and

maximize aesthetic quality helped to usher in the next

generation of autogenous breast reconstructive tech-

niques. In 1989, Koshima and Soeda [17] pioneered

the transfer of abdominal fat and skin without muscle

sacrifice. In 1992, Allen and Treece [7] developed the

DIEP flap for breast reconstruction, based on the

premise that the inclusion of muscle in a flap that is

designed to replace fat and skin is unnecessary. The

muscle-sparing techniques that were used to develop

the DIEP flap have been applied to other donor sites.

Perforator flaps and arterialized skin flaps, including

the deep inferior epigastric artery perforator flap, the

superior gluteal artery perforator flap, and the super-

ficial inferior epigastric artery flap, have moved the

state of the art closer to the ‘‘ideal’’ breast recon-

structive technique [18,19].

Surgical technique

The DIEP flap uses the lower abdomen as a donor

site, as does the TRAM flap. The essential difference

is that the DIEP is based on perforating vessels that

emerge through the rectus sheath from the deep

inferior epigastric vessels. These vessels are followed

through the sheath down to the main feeders and,

therefore, the pedicle is much increased in length.

Preoperative markings are applied while the

patient is in the supine and standing position. Flap

dimensions are marked out in a manner similar to

abdominoplasty planning (Fig. 1). An effort to

Fig. 1. Preoperative markings for a bilateral reconstruction.

Two patterns are demonstrated; the upper design is placed to

safely capture the paraumbilical perforators. Alternatively,

a more aesthetic lower pattern can be used when the

superficial system is used or with beveling in a superior

direction when the DIEP is used.

J.E. Craigie et al / Clin Plastic Surg 30 (2003) 359–369360

include para-umbilical perforators, which are often

dominant, may require shifting of the marked region

slightly superiorly. Alternatively, a more aesthetically

pleasing, lower incision can be used if subcutaneous

beveling in a superior direction is performed (Fig. 2).

A vertical dimension that is greater than 12 cm is

rarely necessary. Horizontal extensions are fashioned

in an effort to limit lateral ‘‘dog ears.’’ The Doppler

probe is used to identify the main perforators of the

medial and lateral branches of the deep inferior

Fig. 2. (A) This demonstrates the more aesthetically oriented, lower donor site incision with beveling in a superior direction during

DIEP flap harvest. (B) This demonstrates the level of undermining in the superior direction to capture the paraumbilical perforators.

J.E. Craigie et al / Clin Plastic Surg 30 (2003) 359–369 361

epigastric artery. On the chest, the inframammary

crease is outlined. With immediate reconstruction,

suggested markings are made for a skin-sparing

mastectomy to include the nipple-areola complex

and biopsy site. A radial extension may be required

to improve access, especially with an axillary dissec-

tion. When a contralateral reduction is planned, the

skin-sparing mastectomy can be performed through a

breast reduction incision to improve symmetry.

The patient is positioned in a supine position with

the arms tucked by her sides. A two-team surgical

approach is used, with simultaneous preparation of the

recipient area and flap harvest. The internal mammary

vessels (IMVs) at the level of the third rib are the

preferred recipients. The advantages of the IMVs over

the thoracodorsal vessels, include ease of positioning

for themicrosurgical assistant, better exposure through

a limited skin sparing incision, and increased liberty

with flap inset [20]. In our experience, preoperative

radiation of the internal mammary vessels has not been

a problem. Radiated vessels are usually more tedious

to dissect but there has not been any increased evi-

dence of postoperative complications compared with

patients who have not undergone radiation.

Flap dissection proceeds with careful elevation of

the skin-fat composite from the underlying rectus

fascia until the lateral perforators are encountered

(Fig. 3). If a large perforator is located, the flap can

be based on this alone or with one or two other lateral

perforating vessels. If no suitable perforators are

identified in the lateral row, the dissection continues

over to the medial row of perforating vessels. The

largest perforators are selected regardless of ‘‘row’’

and the location of these vessels can usually be

predicted preoperatively with the 8 mHz Doppler.

The number of perforators to include in the flap is

based on the size and the perfusion of the flap in vivo.

It is a simple maneuver to isolate the perforators and

individually occlude each significant vessel and check

arterial bleeding at the dermal level. This simple test

can be performed before committing to the perforators

or before complete dissection of the pedicle and

eliminates doubt about perfusion. Conversion to a

muscle flap is never considered. A sensory branch of

the intercostal nerves to the skin paddle can often be

identified accompanying the perforating vessels.

These nerves are dissected along with the vascular

bundle and are used to anastomose to an intercostal

sensory branch in the recipient bed in an effort to

provide sensation in the reconstructed breast.

After the desired perforating vessels are selected,

the defect in the anterior rectus sheath is opened

Fig. 3. Flap dissection proceeds with careful elevation of the skin-fat composite from the underlying rectus fascia until the lateral

perforators are encountered.

J.E. Craigie et al / Clin Plastic Surg 30 (2003) 359–369362

around them (Fig. 4). Loupe magnification and micro-

surgical technique are used to dissect the perforating

artery and veins through the rectus muscle. Often a

second or third perforator, in line with the first, is

maintained with the flap (Fig. 5). In our experience,

approximately 25% of flaps are based on one perfo-

rator, 50% of flaps are based on two perforators, and

25% of flaps are based on three perforators. As

dissection continues, side branches of the vessels are

divided with bipolar coagulation, silk ligatures, or

Fig. 4. The fascia has been opened around two lateral row perforators. The sensory nerve can often be identified with the

perforating vessels.

Fig. 5. Loupe magnification and microsurgical technique are used to dissect the perforating artery and veins through the rectus

muscle. Often, a second or third perforator that is in line with the first is maintained with the flap.

J.E. Craigie et al / Clin Plastic Surg 30 (2003) 359–369 363

clips. The muscle is split along the direction of its

fibers to expose the lateral or medial branch of the deep

inferior epigastric vessels. Intercostal nerves that cross

the pedicle and do not lie between two selected

perforators are preserved. The pedicle is doubly ligated

and divided superior to the take-off point of the most

superior chosen musculocutaneous perforator. The

anterior rectus sheath is split inferiorly and the muscle

fibers are separated to obtain the desired pedicle

length, which typically ranges from 9 cm to 14 cm.

The dissection is usually continued past the point

where the medial and lateral branches converge into

the main deep inferior epigastric artery and vena

comitantes to assure adequately-sized vessels to match

the diameter of the recipient vessels (Fig. 6). After

branches of the pedicle are divided, the skin and fat

flap is a tissue island based on the deep inferior

epigastric artery and vein.

For patients who undergo immediate reconstruc-

tion, the mastectomy specimen is weighed and the

size and shape of skin resection are noted. With

secondary reconstruction, the mastectomy scar is

resected and the chest skin flaps are elevated. The

pectoralis muscle fibers that overlie the third rib at its

junction with the sternum are freed with electro-

cautery, which exposes the underlying costal carti-

lage. For thin patients, the fourth cartilage may be

considered to ensure that the flap covers a potentially

visible depression in the rib donor site. After the

perichondrium is elevated, 2 cm to 3 cm of costal

cartilage is removed. The posterior perichondrium is

carefully opened to expose the internal mammary

vessels. Using loupe magnification, the vessels are

isolated for a distance of 3 cm to 4 cm. The internal

mammary artery (IMA) is usually an excellent recipi-

ent vessel with a diameter of 2 mm to 3 mm. Of the

one or two veins present, the larger vein’s diameter

varies from 2 mm to 4 mm. Although these veins are

often thin-walled, damage during the dissection has

not been problematic when meticulous technique is

used. Care should be taken to avoid opening the

pleura. This has occurred in less than 1% of our

cases; those two cases did not result in pneu-

mothorax. The pedicle is divided and passed under

any crossing intercostal nerves. The harvested flap is

weighed and transferred to the chest wall. It is rotated

180� and the pedicle is laid into the recipient site,

taking care not to twist of the vessels. The flap is

secured in place with #0 silk suture and the operating

microscope is positioned. The larger or only internal

Fig. 6. The dissection is usually continued past the point where the medial and lateral branches converge into the main deep

inferior epigastric artery and vena comitantes to assure adequately sized vessels to match the diameter of the recipient vessels.

J.E. Craigie et al / Clin Plastic Surg 30 (2003) 359–369364

mammary vein is ligated distally and divided. The

anastomosis is completed to the flap vein with a

microvascular coupling device (Micro Companies

Alliance, Birmingham, AL). Attention is then direc-

ted to completion of the anastomosis of the IMA to

the deep inferior epigastric artery with 9.0 nylon

suture. Upon completion of the microvascular ana-

stomosis, an implantable Doppler cuff (Cook Vas-

cular, Inc., Leechburg, PA) is placed around the vein

to provide postoperative monitoring. The cuff is

stabilized with 9.0 nylon sutures and the wire pro-

tector is secured to the chest wall. The handheld

Doppler probe is used to mark the location on the

skin paddle where the perforating arteries enter.

The flap is tailored to achieve the desired breast

size and shape, paying close attention to the weight

of the mastectomy specimen. Using the IMA as the

recipient vessel facilitates medial positioning. Lateral

fullness may be minimized with tacking sutures to

the serratus or lateral pectoralis major muscle. A

closed suction drain is placed and the skin island,

incorporating the arterial perforator marking, is

sutured into place. A temperature strip is applied to

the skin island and a control site to further the

postoperative monitoring.

The opening in the anterior rectus sheath is

closed without tension with a layer of running #0

Panacryl (Fig. 7). The remaining donor site closure

follows standard abdominoplasty closure of the skin

flaps with umbilicoplasty. A suction drain is brought

out through the lateral incision.

Postoperatively, the patient is monitored in the

surgical intensive care unit for 24 hours. No anti-

coagulants are given during or after surgery. Often, a

unit of autologous blood is given, but banked blood is

rarely needed. Monitoring by the nursing staff

includes flap skin color, capillary refill, temperature

referenced to control, and venous and arterial Doppler

signal confirmation. Usually, on the morning after

surgery, the Foley catheter is removed, the intrave-

nous fluids are stopped, and the patient is cleared to

get out of bed. Oral analgesics are typically sufficient

at this point and the patient is usually discharged

home on the fourth postoperative day. Activities are

resumed over the next several weeks and the patient

is given precautionary instructions, including avoid-

ance of prone positioning for 3 to 4 weeks.

Nipple reconstruction and any necessary donor

site revisions are performed at a second stage 6 to

12 weeks after the initial surgery. The patients who

Fig. 7. The opening in the anterior rectus sheath can be closed without tension. The rectus muscle remains intact and viable.

J.E. Craigie et al / Clin Plastic Surg 30 (2003) 359–369 365

undergo immediate reconstructions and skin-sparing

techniques are often afforded the aesthetic benefit of

little or no visible or residual flap skin paddle. Nipple

tattooing follows as the third and final stage of the

reconstructive protocol.

Discussion

Advances in breast reconstruction have been in

response to an increase in demand. The incidence of

breast cancer throughout the industrialized world is

high; the advent of genetic testing, combined with

well-defined clinical and pathologic risk factors,

have increased the indications for therapeutic and

prophylactic mastectomies. Bilateral reconstructions

are frequently required and place more demands than

ever on the plastic surgeon to achieve symmetric and

natural results while minimizing donor site morbid-

ity. Breast reconstruction advances, using perforator

flaps and arterialized skin flaps, have made autoge-

nous reconstruction available to more patients with

less morbidity.

As experience with the DIEP flap has grown

throughout the country, so has the acceptance of the

procedure as a significant step forward in reconstruc-

tive surgery of the breast. Avoidance of muscle

destruction, with a resultant decrease in abdominal

weakness and hernia, are the basic factors that have

established the DIEP flap’s place in the reconstructive

menu. Arguments against the use of this flap as a first

line choice for the patient undergoing mastectomy

have included increased operative time and the need

for microsurgical expertise. The need for microsurgi-

cal proficiency is a given. The procedure requires

meticulous technique and attention to detail. The

surgeon who performs ‘‘occasional’’ microsurgery

would probably do better with a less demanding

operation. Microsurgery has evolved to the point

where high failure rates and marathon surgical times

are no longer a valid counterargument against using a

free flap for breast reconstruction, especially when the

patient is afforded less morbidity compared with

pedicled and free TRAM reconstructions. Our review

of more than 800 cases performed at our institution

showed that the operative times are no longer than the

free TRAM, and may, on occasion, be shorter, as mesh

repair of the abdomen is never required with the DIEP.

The average operative time in this series was 5.4 hours

for unilateral reconstructions and 8 hours for bilateral

Fig. 8. A 45-year-old female 14 months after skin-sparing mastectomy through a breast reduction incision with immediate left

breast DIEP flap reconstruction and a contra lateral breast reduction for symmetry.

J.E. Craigie et al / Clin Plastic Surg 30 (2003) 359–369366

procedures. We have found that the DIEP flap is

particularly well suited for simultaneous, bilateral

reconstruction. Harvesting two skin flaps from the

lower abdomen, without sacrifice of the anterior rectus

sheath or rectus abdominus muscle, significantly

reduces the donor site morbidity that is often associ-

ated with bilateral TRAM flap reconstruction. Avoid-

ing a tight fascial closure and the use of synthetic mesh

allows the patient to be ambulatory on the first post-

operative day. We have found that most patients are

comfortable on oral analgesics alone by postoperative

Day 1. The hospital stay averaged 4.3 days in our

patient population.

Early complications were comparable to other

procedures in this series. The incidence of take-back

to the operative suite was 6.5%. The venous occlusion

rate was 5% and the arterial occlusion rate was 1%.

Since adopting the coupling device as our preferred

method of venous anastomosis, our take-back rate has

dropped even further. Hematoma occurred in 1% of

patients and the total flap loss rate was 1%.

Late complications included seromas in 4% of

patients and delayed abdominal wound healing in

2%. Mesh was never required for fascial repair.

Hernia formation in five of our patients was the result

of unraveling in a continuous suture that was used to

repair the fascial incision; this was easily repaired

with resuturing at a second operation. Fat necrosis

that required revision surgery occurred in 16 of our

patients. These revisions were usually done at the

same time as nipple reconstruction and abdominal

scar revisions, when required.

Smoking did not significantly increase the inci-

dence of early complications; however, late compli-

cations of delayed wound healing and fat necrosis

were significantly increased. The incidence of fat

necrosis that required revision was 13.5% for smok-

ers and 3% for nonsmokers. This compares to

previous reports, which are as high as 26% for

smokers [21]. The incidence of delayed wound

healing was 9% in smokers and 3% in nonsmokers.

Other series have reported rates of delayed wound

healing that ranged from 8% to 27% [22].

The effects of radiation therapy on our patients

were reviewed recently [23]. We found that post-

operative radiation significantly increased the late

Fig. 9. A 45-year-old female, 15 months after right skin-

sparing mastectomy through a periareolar incision and

immediate right breast reconstruction with a DIEP flap.

Fig. 10. A 49-year-old female 19 months after bilateral skin-

sparing mastectomies and immediate bilateral breast recon-

struction with bilateral DIEP flaps.

J.E. Craigie et al / Clin Plastic Surg 30 (2003) 359–369 367

occurrence of fat necrosis in the reconstructed breast

and can substantially compromise the aesthetic result.

We no longer recommend immediate reconstruction

for patients who are scheduled for radiation after

surgery. Delayed reconstruction is undertaken in this

group 6 months after completion of their therapy to

allow the acute effects of their treatments to settle.

Recent publications by other investigators on their

experience with the DIEP flap raised questions about

venous congestion and the selection criteria for the use

of the flap [24,25]. Proponents of muscle flaps often

convert to a free TRAM to avoid congestion and

perfusion problems if the perforator vessels do not

appear robust or if flap volume requirements are large.

We do not share this philosophy and rarely have

experienced venous congestion. To manage this prob-

lem, our strategies are to include multiple perforators

in the flap and to preserve the superficial inferior

epigastric vein to provide additional venous outflow if

needed. Additional routes for venous outflow with an

additional microvascular anastomosis rarely are

needed, but we are prepared to address this problem

with additional efforts intraoperatively to avoid the

increased donor site morbidity that is associated with

muscle sacrifice. Our experience with this flap has

been extensive and our success has not been compro-

mised by muscle preservation.

Fig. 11. A 53-year-old female 6 months after bilateral skin-

sparing mastectomies and immediate bilateral reconstruction

with bilateral DIEP flaps.

Fig. 12. A 55-year-old female 19 months after delayed reconstruction of a right modified radical mastectomy defect and

simultaneous left breast reduction.

J.E. Craigie et al / Clin Plastic Surg 30 (2003) 359–369368

Summary

Muscle-sparing autogenous breast reconstruction

has enhanced the multidisciplinary care that is avail-

able to patients who have breast cancer. The DIEP flap

has proven reliability, a low complication rate, and is

applicable to many clinical scenarios (Figs. 8–12).

Avoidance of muscle sacrifice in the abdomen ulti-

mately translates into greater patient satisfaction. The

increased demands, in terms of surgical expertise, are

more than offset by decreased postoperative pain and

decreased donor site morbidity. The methods that were

used to innovate the DIEP flap have been applied to

other donor sites and the available options for patients

have been expanded.

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