Clinical Scenarios Using Thoracodorsal and Lateral Thoracic Vessels Versus Internal Mammary Vessels in Bipedicled...

Autologous breast reconstruction using the bipedicled deep inferior epigastric perforator (DIEP) flap poses unique challenges in Asian patients with a low BMI and limited donor volume. While internal mammary vessels (IMA/Vs) remain the standard recipient site, the rise of minimally invasive mastectomy has limited access to IMA/Vs. This study compared the results of thoracodorsal and lateral thoracic vessels (lateral-based) versus IMA/Vs (medial-based) in bipedicled DIEP flap breast reconstruction.

A retrospective review was conducted on 62 patients who underwent bipedicled DIEP flap reconstruction between 2018 and 2023 by a single senior surgeon. Patients were stratified by incision placement and recipient vessel choice into medial- and lateral-based groups. Clinical outcomes, complication rates, and long-term aesthetic results were analyzed.

Despite a higher re-exploration rate in the lateral-based group (12.5% versus 4.5%; p = 0.298), flap survival was comparable between the groups. Fat necrosis rates were lower in flaps without re-exploration (5.4%) and increased significantly following compromised perfusion (33.3%). The lateral-based group achieved superior aesthetic outcomes in breast shape (p = 0.043) and scar visibility (p < 0.001), with a reduced need for secondary fat grafting. Dual vascular sources provided more reliable perfusion and improved long-term fat survival, although further validation with perfusion imaging is warranted.

The lateral-based approach, despite technical challenges, is a viable alternative to the medial-based method in certain patients, offering reliable perfusion and superior aesthetic outcomes with fewer revisions. An algorithmic approach to recipient vessel selection can optimize outcomes of bipedicled DIEP flap reconstruction.