A study published in the May edition of "Plastic and Reconstructive Surgery" has shown that patients who have had previous abdominal surgery are at an increased risk of suffering abdominal complications following DIEP flap breast reconstruction. Here is the abstract:
DIEP Flaps in Women with Abdominal Scars: Are Complication Rates Affected?
Plastic & Reconstructive Surgery. 121(5):1527-1531, May 2008.
Parrett, Brian M. M.D.; Caterson, Stephanie A. M.D.; Tobias, Adam M. M.D.; Lee, Bernard T. M.D.
Background: Previous abdominal surgery may affect perforator anatomy and complication rates in patients undergoing deep inferior epigastric perforator (DIEP) flap breast reconstruction. The purpose of this study was to determine whether abdominal scars in DIEP breast reconstruction have an effect on flap and donor-site complications.
Methods: Over a 3-year period, 168 DIEP flap patients were retrospectively divided into a control group with no previous abdominal operations and a scar group with previous abdominal procedures. Flap and abdominal wound complications were compared between the two groups.
Results: Ninety patients (54 percent) underwent 114 flaps in the control group and 78 patients (46 percent) underwent 104 flaps in the scar group. The most common previous incisions were Pfannenstiel, laparoscopic, and midline. There was no significant difference between the groups in age, body mass index (mean 27 kg/m2 in both groups), smoking history, or radiation status. There were no significant differences between the control and scar groups in DIEP flap loss (1.8 percent versus 2.9 percent), partial flap loss (1.8 percent versus 1.0 percent), or fat necrosis (15 percent versus 14 percent, respectively). However, the scar group had a significantly higher rate of abdominal donor-site complications (24 percent) compared with the control group (6.7 percent; p = 0.003). The most common complications were abdominal wound breakdown (12 percent), seroma requiring operative drainage (6.4 percent), and abdominal laxity or bulge (5.1 percent).
Conclusions: With minor technical modifications, DIEP flaps can be performed successfully without increased flap complications in patients with preexisting abdominal incisions. Despite these design modifications, patients should be informed of an increased risk for donor-site complications.
Here's my take...
While we have not seen such a high rate of complications in our practice, I agree with the conclusions of this study completely. There is no question that the DIEP flap procedure is associated with far fewer abdominal complications than the TRAM flap. However, that does not mean that DIEP surgery is free of risk.
The complexity of any surgery and the potential complications increase when operating on parts of the body that have undergone previous surgeries. The abdomen is no different to any other part of the body. Patients undergoing DIEP flap breast reconstruction must be aware that they are facing increased risk in terms of abdominal complications compared to patients that have never had abdominal surgery. This study has underlined this. As a general rule of thumb, the more scars on your belly the higher your risk probably is.
I personally would have liked this study to have included a second group of patients that had undergone TRAM flaps (instead of DIEP flaps) for comparison of complication rates between the 2 groups. If the complication rate is 24% for a DIEP patient, what is it for a TRAM patient that has had multiple previous surgeries? Results of previous studies suggest that it would be even higher in TRAM patients.
It is also important to remember however that just because a patient has had previous abdominal surgery does not mean they are not a DIEP candidate. While the patient must be informed of the increased risks, previous abdominal surgery is not a reason to deprive her of what is very likely still her best reconstructive option.
Dr Chrysopoulo is board certified in Plastic and Reconstructive Surgery and specializes in breast reconstruction surgery after mastectomy for breast cancer. He and his partners perform hundreds of microsurgical breast reconstructions with perforator flaps each year including the DIEP flap procedure. PRMA Plastic Surgery, San Antonio, Texas. Toll Free: (800) 692-5565. Keep up to date with the latest breast reconstruction news by following Dr Chrysopoulo's Breast Reconstruction Blog.