Algorithmic approach to the design and harvest of abdominal flaps for microvascular breast reconstruction in patients with abdominal scars.

INTRODUCTION

Risk of abdominal free flaps complications and the risk of abdominal wound complications from surgery are significantly increased in patients with previous abdominal surgeries. Previous scars can limit the vascularized territories suitable for transfer and can lead to significant partial flap necrosis.

METHODS

A retrospective review of abdominal free flap breast reconstructions performed by the senior author (GKL) over 5 years (2008-2013). Patients were grouped based on the presence or absence of abdominal scars and specific type/location of scar(s). In addition, we analyzed patient information. including demographics, body mass index, smoking history, comorbid conditions, and most importantly, surgical techniques to optimize vascular perfusion.

RESULTS

We identified 169 patients that underwent abdominal perforator free flap breast reconstruction. One hundred nine patients underwent previous abdominal surgery. Within this group, we had 2 complete flap losses, 5 major flap complications, 9 minor flap complications, and 9 donor site complications. Sixty patients had no previous abdominal surgery. Of these patients, we had no complete flap losses, 2 major flap complications, 1 minor flap complication, and 4 donor site complications. Patients with previous abdominal surgeries undergoing abdominal free flap breast reconstruction had a statistically significant higher rate of flap complications (P=0.02). Donor site wound healing complications were not statistically significant (P=0.5). The subgroup of patients that had both a previous intra-abdominal surgery scar and Pfannenstiel scar (21 patients) were at greatest risk for both free flap (19% of patients) and donor site wound healing (19% of patients) complications.

CONCLUSIONS

Abdominal scars increase the risk of complications to the free flap. Unlike previous studies, patients with abdominal scars do not appear to have a statistically significant increase for donor site complications. Using the data from our study, we developed an algorithm for abdominal flap harvest in patients with abdominal scars. The algorithm emphasizes the importance of bipedicled perforator flaps and supercharging/turbocharging when blood flow is required across scars or when a large volume of tissue is needed crossing the midline. In specific cases, where perforator viability is in question because of a previous abdominal surgical procedure, we recommend the inclusion of muscle (Muscle-Sparing-transverse rectus abdominis musculocutaneous vs transverse rectus abdominis musculocutaneous).