Donor site morbidity following DIEP flap for breast reconstruction in Asian patients: Is it different?

A DIEP Dive into Patient Risk Factors for Hernia and Bulge Development: A Meta-regression

BACKGROUND

 This meta-regression aims to investigate risk factors for abdominal hernia and bulge in patients undergoing deep inferior epigastric perforator (DIEP) flaps and the effect of prophylactic mesh placement on postoperative complications.

METHODS

 A systematic search was conducted in July of 2022 in alignment with the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Seventy-four studies published between 2000 and 2022 met the inclusion criteria. Sixty-four studies were included in the analysis for bulge and 71 studies were included in the analysis for hernia. Meta-regressions were run on the proportion of patients experiencing hernia or bulge to assess for patient risk factors and the role of prophylactic mesh placement. Proportions were transformed using the Freeman-Tukey double arcsine method.

RESULTS

 The average rates of hernia and bulge after DIEP flaps were found to be 0.18% and 1.26%, respectively. Increased age (β = 0.0059, p = 0.0117), prior abdominal surgery (β = 0.0008, p = 0.046), and pregnancy history (β = -0.0015, p = 0.0001) were significantly associated with hernia. Active smoking (β = 0.0032, p = 0.0262) and pregnancy history (β = 0.0019, p < 0.0001) were significantly associated with bulge. Neither the perforator vessel laterality nor the number of perforator vessels harvested had any association with hernia or bulge. Prophylactic mesh placement was not associated with hernia or bulge.

CONCLUSION

 Understanding the comorbidities associated with hernia or bulge following DIEP flap breast reconstruction, such as advanced age, prior abdominal surgery, pregnancy history, and active smoking status, allows surgeons to proactively identify and educate high-risk patients. Future studies may further explore whether prophylactic mesh placement offers patients any benefit.

Long-term Donor Site-related Quality of Life after Deep Inferior Epigastric Perforator Flap Breast Reconstruction

Background

Current knowledge about patients' perceptions of the donor site following abdominal-based breast reconstruction and its effect on health-related quality of life (HRQoL) several years after breast reconstruction is limited. This study aimed to assess the long-term effects of deep inferior epigastric perforator (DIEP) flap breast reconstruction on HRQoL, specifically focusing on the abdomen and donor site aspects.

Methods

This retrospective cohort study compared 66 women who underwent DIEP breast reconstruction between 2000 and 2007 with a matched control cohort of 114 women who underwent therapeutic mastectomies without reconstruction in the year 2005. The DIEP cohort of patients completed the BREAST-Q Reconstruction module during an outpatient visit in 2015-2016. The control cohort completed the same questionnaire online in 2016.

Results

The follow-up time was at least 8 years (mean 11.4 ± 1.6 years) postreconstruction for the DIEP cohort and 10 years postmastectomy (mean 11.0 ± 0.3 years) for the control cohort. In the DIEP cohort, 93% reported no donor site pain, 89% had no difficulty sitting up, and 91% had no activity limitations 2 weeks before completing the survey. Patients undergoing DIEP were more satisfied with their abdominal appearance than the control group (adjusted OR, 5.7; 95% confidence interval 1.8-17.6).

Conclusions

A decade postoperatively, DIEP breast reconstruction yields high abdominal donor site satisfaction, with comparable abdominal physical well-being to nonreconstructed women.

Safety of Drainless Donor Closure in DIEP Flap-Based Breast Reconstruction: A Prospective Analysis Using Ultrasound

BACKGROUND

 Although drainless donor closure with progressive tension suture (PTS) technique has been attempted to further reduce donor morbidity in deep inferior epigastric perforator (DIEP) flap-based breast reconstruction, its clinical safety has not yet been fully elucidated. This study prospectively investigated donor morbidity after DIEP flap elevation and drain-free donor closure.

METHODS

 A prospective cohort study was performed on 125 patients who underwent DIEP flap-based breast reconstruction and drainless donor closure. Postoperatively, the donor site was evaluated repetitively using ultrasonography. Development of donor complications, including any fluid accumulation and seroma (defined as detection of fluid accumulation after postoperative one month), was prospectively noted, and independent predictors for the adverse events were evaluated.

RESULTS

 On ultrasound examination conducted within postoperative 2 weeks, 48 patients were detected to have fluid accumulation at the donor site, which were more frequently detected in cases of delayed reconstruction and those with lesser number of PTS conducted. The majority of those events (95.8%) were resolved with one- or two-times ultrasound-guided aspirations. Five patients (4.0%) showed persistent fluid accumulation after postoperative 1 month, which were successfully treated with repetitive aspiration without requiring reoperation. No other abdominal complications developed except for three of delayed wound healing. On multivariable analyses, harvesting larger-sized flap and conducting lesser number of PTS were independent predictors for the development of fluid accumulation.

CONCLUSION

 The results of this prospective study suggest that drainless donor closure of the DIEP flap with meticulous placement of PTS followed by postoperative ultrasound surveillance appears to be safe and effective.

A Machine Learning Approach to Predicting Donor Site Complications Following DIEP Flap Harvest

BACKGROUND

 The additional donor site incisions in autologous breast reconstruction can predispose to abdominal complications. The purpose of this study is to delineate predictors of donor site morbidity following deep inferior epigastric perforator (DIEP) flap harvest and use those predictors to develop a machine learning model that can identify high-risk patients.

METHODS

 This is a retrospective study of women who underwent DIEP flap reconstruction from 2011 to 2020. Donor site complications included abdominal wound dehiscence, necrosis, infection, seroma, hematoma, and hernia within 90 days postoperatively. Multivariate regression analysis was used to identify predictors for donor site complications. Variables found significant were used to construct machine learning models to predict donor site complications.

RESULTS

 Of 258 patients, 39 patients (15%) developed abdominal donor site complications, which included 19 cases of dehiscence, 12 cases of partial necrosis, 27 cases of infection, and 6 cases of seroma. On univariate regression analysis, age (p = 0.026), body mass index (p = 0.003), mean flap weight (p = 0.006), and surgery time (p = 0.035) were predictors of donor site complications. On multivariate regression analysis, age (p = 0.025), body mass index (p = 0.010), and surgery duration (p = 0.048) remained significant. Radiographic features of obesity, such as abdominal wall thickness and total fascial diastasis, were not significant predictors of complications (p > 0.05). In our machine learning algorithm, the logistic regression model was the most accurate at predicting donor site complications with the accuracy of 82%, specificity of 0.93, and negative predictive value of 0.87.

CONCLUSION

 This study demonstrates that body mass index is superior to radiographic features of obesity in predicting donor site complications following DIEP flap harvest. Other predictors include older age and longer surgery duration. Our logistic regression machine learning model has the potential to quantify the risk of donor site complications.

Effect of Incision Negative Pressure Wound Therapy on Donor Site Morbidity in Breast Reconstruction with Deep Inferior Epigastric Artery Perforator Flap

Background

The usefulness of closed incision negative pressure wound therapy (ciNPWT) has been well documented in many surgical sites, except for the donor site of the deep inferior epigastric artery perforator (DIEP) flap. The aim of this study was to evaluate the effect of ciNPWT on microsurgical breast reconstruction using a DIEP flap.

Methods

Fifty-six cases of breast reconstruction with DIEP flap were included and divided into two groups based on post-surgical wound management: the ciNPWT group received ciNPWT at the donor site, while the conventional group received conventional wound management. The primary outcomes were the incidence of seroma, wound dehiscence, and surgical site infection, and secondary outcomes were the time to drain removal and amount of drainage. The breast reconstruction risk assessment (BRA) score was used to evaluate the comprehensive risk in each case.

Results

Among the patient and surgical characteristics, only the BRA score (P=0.02) and the time to elevate the flap (P=0.02) were significantly higher and longer in the ciNPWT group, respectively. The incidence of seroma, dehiscence, and wound infection showed no significant difference between the two groups. In the subgroup analysis of patients with body mass index ≥ 25, the primary outcomes did not differ, while the secondary outcomes were significantly lower in the ciNPWT group (drainage volume, P = 0.04; time to drain removal, P = 0.04)

Conclusion

ciNPWT can potentially reduce the incidence of donor site complications of DIEP flaps, especially if the comprehensive risk for post-surgical complications is considered.

Ethnicity-based differences in thrombosis in lower extremity vascular bypass: a review of current literature

INTRODUCTION

Understanding prothrombotic factors is important in vascular surgery for surgical planning, preoperative evaluation, and post-operative management. The purpose of this study was to investigate ethnicity-based differences in coagulation between East Asian and Western cohorts by comparing patency rates after infrainguinal bypass surgery.

EVIDENCE ACQUISITION

A review of infrainguinal bypass patients was conducted for East Asian (including Chinese, Japanese, and Korean) and Western (North American and European) studies between 1990 and 2015 within the Journal of Vascular Surgery. The number of patent grafts at 1-year and 5-years were calculated from reported patency rates for PTFE grafts, Dacron grafts, all prosthetic grafts, autogenous grafts, and all grafts. Statistical analysis was performed using Chi-square test for each graft type at each time point.

EVIDENCE SYNTHESIS

A total of 9972 grafts from 50 studies were included in our review. There were 3592 grafts from East Asian patients and 6380 grafts from Western patients. There was a statistically significant (P<0.05) difference between East Asian and Western cohorts in both 1-year and 5-year patency rates for PTFE, all prosthetic, and all grafts.

CONCLUSIONS

East Asians had significantly higher patency rates after infrainguinal bypass surgery for PTFE, all prosthetic, and all graft types compared with Westerners, showing an ethnicity-based difference in thrombosis. Further research is needed to identify the specific genetic or dietary influences causing this significant difference.

Analysis of 461 Consecutive Patients’ Donor Site Morbidity following Abdominal Tissue-Based Breast Reconstruction without Fascia Reinforcement Graft

Despite the popularity of breast reconstruction with abdominal flap, the integrity of the abdominal wall gets compromised after the operation. To decrease donor site morbidity, researchers have developed various inlay or onlay graft materials. However, the indications of use are unclear and dependent on the subjective decision of the surgeons. In this study, we have investigated donor site morbidities in breast reconstruction with free abdominal flap surgery in which graft materials were not used. We reviewed 461 consecutive cases for the preoperative characteristics of patients, intraoperative details, and postoperative donor site complications from May 2013 to March 2019. While 386 patients underwent deep inferior epigastric perforators (83.7%), muscle sparing type 2 transverse rectus abdominis musculocutaneous flaps were performed in 75 patients (16.3%). Bilateral dissection of the pedicle was performed in 162 patients, compared to unilateral dissection in 299 patients. The mean follow-up duration was 22.7 months. The overall complication rate in the donor site was 7.2%. The flap height was significantly associated with the overall complication. While majority of them were delayed wound healing ( $n=28$ , 6.1%), there were four cases of hematoma (0.9%). There were two cases of bulging (0.4%), which occurred in patients receiving bipedicle dissection; however, there was no case of hernia. Conclusions. Breast reconstruction with an abdominal free flap can be safely performed without fascia reinforcement graft even with bilateral dissection of the pedicle. With complete preservation of fascia and zigzag fascial incision, a low incidence of abdominal bulging can be obtained even with bilateral harvesting of the flap.

The Influence of Closing the Abdominal Donor-Site Superficial Fascial System in Deep Inferior Epigastric Perforator Flap Breast Reconstruction

BACKGROUND

The superficial fascial system is routinely closed to alleviate tension at the abdominal donor site after harvest of the deep inferior epigastric artery perforator flap (DIEP) for breast reconstruction. This is thought to decrease rates of wound dehiscence and improve contour postoperatively. There has been no comparative analysis on closure of the superficial fascial system and its effect on donor-site outcomes.

METHODS

The authors retrospectively evaluated outcomes of DIEP flap breast reconstructions performed between 2017 and 2019. After May of 2018, the surgeons collectively agreed to stop closure of the superficial fascial system. All subsequent patients underwent closure of rectus abdominis fascia followed by skin closure. Patient demographic data and abdominal donor-site comorbidities were recorded between the superficial fascial system closure and no-superficial fascial system closure groups. Representative photographs of patients from the two groups were blindly assessed for scar appearance and contour using previously published grading scales. The results were compared.

RESULTS

DIEP flap breast reconstruction was performed in 103 consecutive women. Among patients with abdominal donor-site reconstruction, 66 had superficial fascial system closure and 37 did not. There was not a significant difference in fat necrosis or wound dehiscence between the two groups (p = 0.29 and p = 0.39, respectively). Postoperative abdominal scar and contour were evaluated by 10 independent raters and showed no significant difference between the two groups.

CONCLUSION

Omission of superficial fascial system closure resulted in no difference in wound dehiscence or fat necrosis rates and aesthetic appearance of the abdominal scar and contour.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Validating machine learning approaches for prediction of donor related complication in microsurgical breast reconstruction: a retrospective cohort study

Autologous reconstruction using abdominal flaps remains the most popular method for breast reconstruction worldwide. We aimed to evaluate a prediction model using machine-learning methods and to determine which factors increase abdominal flap donor site complications with logistic regression. We evaluated the predictive ability of different machine learning packages, reviewing a cohort of breast reconstruction patients who underwent abdominal flaps. We analyzed 13 treatment variables for effects on the abdominal donor site complication rates. To overcome data imbalances, random over sampling example (ROSE) method was used. Data were divided into training and testing sets. Prediction accuracy, sensitivity, specificity, and predictive power (AUC) were measured by applying neuralnet, nnet, and RSNNS machine learning packages. A total of 568 patients were analyzed. The supervised learning package that performed the most effective prediction was neuralnet. Factors that significantly affected donor-related complication was size of the fascial defect, history of diabetes, muscle sparing type, and presence or absence of adjuvant chemotherapy. The risk cutoff value for fascial defect was 37.5 cm². High-risk group complication rates analyzed by statistical method were significant compared to the low-risk group (26% vs 1.7%). These results may help surgeons to achieve better surgical outcomes and reduce postoperative burden.

The island-type pedicled TRAM flap: Improvement of the aesthetic outcomes of breast reconstruction

BACKGROUND

The pedicled transverse rectus abdominis myocutaneous flap (TRAM) remains an effective and widely-used method for breast reconstruction despite well-documented donor-site morbidity. We present the island-type pedicled TRAM flap as a way to obtain better and more reliable outcomes in breast reconstruction.

METHODS

A retrospective chart review of patients who underwent breast reconstruction with an island-type pedicled TRAM flap was performed. Patient demographics and complications were reviewed. In the island-type pedicled TRAM flap, we transversely resected the upper ipsilateral rectus muscle surrounding the origin of the superior epigastric vessels, preserving only a 1-cm muscle strip including the vascular pedicle to prevent epigastric bulging and inframammary fold (IMF) disruption. The flap was turned over into the ipsilateral breast pocket. The IMF was repaired except for the portion where the pedicle was placed.

RESULTS

From January 2013 to November 2017, 88 patients underwent surgery using the island-type pedicled TRAM flap. The etiology of the defect was breast cancer with mastectomy in 86 cases, and paraffinoma in two cases. Seventy-seven patients underwent unilateral reconstruction, and 11 patients underwent bilateral reconstruction. Minor fat necrosis occurred in eight cases. Mild inframammary or epigastric bulging was observed in five cases, and neither partial nor total flap necrosis was observed. The aesthetic outcome of the IMF was evaluated in 55 cases, and 53 cases received good overall scores.

CONCLUSION

Although the island-type pedicled TRAM flap is technically challenging because careful dissection and pedicle identification is required, it can provide more reliable and better aesthetic results without an increased risk of vascular compromise.

Impact of Rectus Muscle Injury during Perforator Dissection on Functional Donor Morbidity after Deep Inferior Epigastric Perforator Flap Breast Reconstruction

This study aimed to assess the extent of rectus muscle damage in deep inferior epigastric perforator (DIEP) flap harvest and to evaluate its association with functional donor morbidity.

A Meta-analysis of Clinical, Patient-Reported Outcomes and Cost of DIEP versus Implant-based Breast Reconstruction

Comparative data on clinical outcomes and cost of deep inferior epigastric perforator (DIEP) and implant-based reconstruction (IBR) are limited. We conducted a Preferred Reporting Items for Systematic Review and Meta-analysis-compliant systematic review and meta-analysis to compare clinical, patient-reported outcomes (PROs) and cost.

Reconstruction of moderate-sized soft tissue defects in foot and ankle in children: Free deep inferior epigastric artery perforator flap versus circumflex scapular artery perforator flap

BACKGROUND

This retrospective study was conducted to compare the outcomes between the free deep inferior epigastric artery perforator (DIEP) flap and the circumflex scapular artery perforator (CSAP) flap in reconstruction of moderate-sized soft tissue defects in the foot and ankle of pediatric patients.

PATIENTS AND METHODS

From January 2004 to December 2016, 42 patients, ranging from 2 to 13 years old, underwent foot and ankle reconstruction, with a free DIEP flap in 21 cases and a free CSAP flap in the other 21cases.

RESULTS

All the flaps survived. No marked differences were observed in the demographics, flap size, recipient vessels, and overall early or late complication rate (p > 0.05). The CSAP group had a shorter operation time (134.3 ± 25 min vs. 202.4 ± 24.3 min, p < 0.05) and flap harvest time (29.7 ± 8.1 min vs. 52.2 ± 9.8 min, p < 0.05) than the DIEP group had. In long-term follow-up, the CSAP group showed a lower fat hyperplasia rate (14% vs. 52%, p < 0.05) and better cosmetic outcomes than the DIEP group did (p < 0.05). The functional outcomes had no marked differences (p > 0.05).

CONCLUSIONS

The DIEP flap and the CSAP flap are both good options for foot and ankle reconstruction of moderate-sized defects in pediatric patients. The CSAP flap has a shorter operation time and flap harvest time, a lower fat hyperplasia rate, and better long-term cosmetic outcomes than the DIEP flap does.

Spontaneous rupture of abdominal wall after breast reconstruction using deep inferior epigastric perforator flap following mastectomy for breast cancer

BACKGROUND

The demand for breast reconstruction after mastectomy is rising. The use of deep inferior epigastric perforator (DIEP) flap in autologous reconstruction is a popular approach. There were some reports about abdominal complications after breast reconstruction. However, there was no report about spontaneous rupture of abdominal wall.

CASE PRESENTATION

A 46-year-old female patient was diagnosed with left breast cancer. Left mastectomy with sentinel lymph node biopsy was performed, and the breast was reconstructed using DIEP flap simultaneously. She suffered heavy abdominal pain and vomiting at postoperative day 4. Computed tomography showed bowel herniation into the subcutaneous tissue caused by left abdominal wall rupture. The abdominal wall was sutured and repaired using mesh by emergency surgery.

CONCLUSIONS

To the best of our knowledge, this is the first case about spontaneous rupture of abdominal wall after breast reconstruction using DIEP flap to be reported in the English literature. DIEP flap on breast reconstructive surgery may cause spontaneous rupture of abdominal wall.

Volume change in the rectus abdominis muscle after deep inferior epigastric perforator flap harvest

Deep inferior epigastric perforator (DIEP) flap is associated with less donor site morbidity than transverse rectus abdominis myocutaneous flap. However, abdominal muscle atrophy and donor site complications caused by denervation during pedicle dissection cannot be avoided. This retrospective study investigated the change in the rectus abdominis muscle volume after DIEP flap harvest. Of 395 patients who underwent unilateral DIEP flap breast reconstruction between August 2007 and July 2017, 25 patients with >2-year postoperative abdominal computed tomography data were evaluated. Preoperative and postoperative images of the abdominal muscle after pedicle dissection and the nonoperated side were compared. The volume of the muscles from the lower margin to the umbilicus was determined by using OsiriX image analysis application. The muscle volumes on the side of pedicle dissection decreased from 72.63 ± 23.29 cm³ preoperation to 53.09 ± 16.93 cm³ postoperation (p < 0.001). The corresponding volumes on the side without dissection were 73.29 ± 19.25 cm³ and 60.89 ± 18.79 cm³ (p < 0.001). The percentage of postoperative retained volume relative to the preoperative retained volume was 75.65% ± 19.18% on the pedicle dissection side and 84.65% ± 19.00% on the contralateral side. The 9% difference was not statistically significant (p = 0.10). No major abdominal complications were observed. Despite nerve injury during DIEP flap surgery, the volume loss of the involved and contralateral muscles did not differ. More than 75% of the abdominal muscle volume was retained. Muscle integrity was well maintained without any postoperative complications.

Weight analysis of mastectomy specimens and abdominal flaps used for breast reconstruction in Koreans

BACKGROUND

Slim patients or those with large breasts may be ineligible for breast reconstruction with an abdominal flap, as the volume of the flap may be insufficient. This study aimed to establish that abdominal tissue-based breast reconstruction can be well suited for Korean patients, despite their thin body habitus.

METHODS

A total of 252 patients who underwent postmastectomy breast reconstruction with an abdominal flap from October 2006 to May 2013 were retrospectively reviewed. The patients' age and body mass index were analyzed, and a correlation analysis was performed between the weight of the mastectomy specimen and that of the initial abdominal flap.

RESULTS

The average weights of the mastectomy specimen and initial abdominal flap were 451.03 g and 644.95 g, respectively. The ratio of the weight of the mastectomy specimen to that of the initial flap was 0.71±0.23. There was a strong positive linear relationship between the weight of the mastectomy specimen and that of the initial flap (Pearson correlation coefficient, 0.728). Thirty nulliparous patients had a final-to-initial flap weight ratio of 0.66±0.11. The 25 patients who underwent a contralateral procedure had a ratio of 0.96±0.30. The adjusted ratio of the final flap weight to the initial flap weight was 0.66±0.12.

CONCLUSIONS

Breast weight had a strong positive relationship with abdominal flap weight in Koreans. Abdominal flaps provided sufficient soft tissue for breast reconstruction in most Korean patients, including nulliparous patients. However, when the mastectomy weight is estimated to be >700 g, a contralateral reduction procedure may be considered.

The Influence of a Pfannenstiel Scar on Venous Anatomy of the Lower Abdominal Wall and Implications for Deep Inferior Epigastric Artery Perforator Flap Breast Reconstruction

BACKGROUND

A Pfannenstiel incision involves the obstruction of superficial venous pathways and functional diversion of flow through alternative pathways and adjacent vessels. This study investigated the effect of a prior Pfannenstiel incision on venous anatomy of the lower abdominal wall; specifically, the superficial inferior epigastric vein (SIEV), using computed tomographic angiography.

METHODS

A case-control study was performed of 50 patients with Pfannenstiel scars and 50 age-matched, body mass index-matched control patients without Pfannenstiel scars. The authors compared the number of direct/indirect and total communications between the SIEV and deep inferior epigastric artery perforator (DIEP) venae comitantes, midline crossover, and other SIEV-related anatomical changes by using computed tomographic angiography. Flap-related clinical outcomes and donor-site-related complications were also assessed.

RESULT

The median number of direct and total communications between the SIEV and DIEP venae comitantes in the study group was greater than in the control group. The percentage of SIEVs having more than two branching patterns per hemiabdomen was significantly higher in the study group than in the control group. The study group also showed a significantly lower rate of fat necrosis compared with the control group (p = 0.03). The rate of donor-site seroma was significantly higher in the study group.

CONCLUSION

This study suggests that the presence of a Pfannenstiel scar may promote the development of direct and total communications between the SIEV and DIEP venae comitantes and branching within the SIEV in the lower abdominal wall, which may facilitate venous drainage of adipose tissue in DIEP flap breast reconstruction.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, II.

Vertically Set Sombrero-shaped Abdominal Flap for Asian Breast Reconstruction after Skin-sparing Mastectomy

Supplemental Digital Content is available in the text.

Background:

Immediate autologous breast reconstruction after skin-sparing mastectomy is an esthetically superior method, and a free abdominal flap is often used. However, in Asian patients, little redundant abdominal skin and thin subcutaneous tissue are common, necessitating the development of a more suitable flap design and setting. We devised a narrow flap, the sombrero-shaped flap (S-flap), set vertically, to reduce postoperative abdominal morbidity without sacrificing cosmetic results.

Methods:

To assess this new flap design and setting, the recipient- and donor-site complications of consecutive patients treated by S-flap (n = 40) and conventional flap (C-flap) (n = 22) were retrospectively investigated. Postoperative abdominal pain, stiffness, and patient activity were also assessed in each group with our original grading scale.

Results:

Compared with the C-flap group, the S-flap group had a significantly lower skin paddle vertical height (mean, 14.0 and 10.2 cm, respectively; P < 0.001), lower abdominal stiffness (P = 0.023), and higher rate of double-pedicled flap use (27.3% and 52.5%, respectively; P < 0.048). The rates of donor and recipient site complications, postoperative abdominal pain, and activity did not significantly differ between the groups.

Conclusions:

For immediate breast reconstruction after skin-sparing mastectomy in Asian patients, our newly designed S-flap and vertical flap setting achieved cosmetically good, consistent results with low abdominal morbidity, even though the abdominal flap was thin and narrow. The viability of the S-flap, including medial fan-shaped adipose flap, was reliable, even though the flap often required elevation with double pedicles.