Buried Autologous Breast Reconstruction: Outcomes and Technical Considerations

The purpose of this study is to compare outcomes in patients undergoing buried and non-buried free flaps for breast reconstruction, in addition to evaluating the safety and reliability of venous flow couplers. A retrospective review was performed of all patients undergoing free flap breast reconstruction between 2013 and 2023. The primary outcomes were free flap failure, complications and the number of procedures required to complete the reconstructive journey. A total of 322 flaps were performed in 254 consecutive patients, with 47.5% (n = 153) being buried and 52.0% (n = 169) being non-buried reconstructions. The most common flap of choice being deep inferior epigastric artery perforator flaps (81.9%) followed by profunda artery perforator flaps (14.3%). There was no significant difference between the two groups in complications, including flap failure (buried 2.0% vs. non-buried 1.8% p = 0.902). There was a significant reduction in the number of procedures required to complete the reconstructive journey, with 52.2% (n = 59) of patients undergoing single-stage breast reconstruction in the buried group compared with only 25.5% (n = 36) in the non-buried group (p < 0.001). Two (0.6%) patients experienced a false negative in which the signal of the flow coupler was lost but the flap was perfused during re-exploration. No flap losses occurred without being identified in advance by a loss of audible venous flow signal. Buried free flap breast reconstruction is safe and requires fewer operations to complete patients' reconstructive journey. Flow couplers are a safe and effective method of monitoring buried free flaps in breast reconstruction.