Breast Reconstruction Flap Options

Primary Flap Options

The American College of Radiology recommends the Deep Inferior Epigastric Perforator (DIEP) flap as the preferred autologous option for breast reconstruction, providing optimal tissue volume from the lower abdomen while preserving the rectus abdominis muscle, resulting in superior donor site outcomes compared to muscle-sacrificing alternatives 1, 2
The DIEP flap preserves the entire rectus abdominis muscle, eliminating the donor site morbidity associated with traditional TRAM flaps while providing equivalent reconstructive outcomes 1, 3
The DIEP flap results in less fat necrosis, reduced hernia risk, and preserved abdominal wall function compared to transverse rectus abdominis muscle (TRAM) flaps 1
The ideal perforator for the DIEP flap should be large caliber, medially located within the flap, with an extended vascular territory beyond the midline to provide optimal perfusion 1, 4
The latissimus dorsi myocutaneous flap is a useful alternative option, particularly when radiation therapy is anticipated, as autologous tissue tolerates radiation better than implants 2, 5

The American College of Radiology recommends CT angiography (CTA) of the abdomen and pelvis with IV contrast as the gold standard for preoperative planning of DIEP flaps, with 96% sensitivity for all perforators and 100% sensitivity for perforators >1 mm 6
Preoperative imaging with CT angiography or MR angiography demonstrates decreased operative time, reduced flap loss rate, decreased hernia rate, reduced intraoperative blood loss, and shorter hospital stays compared to handheld Doppler alone 6

Perforators are ranked based on size (largest caliber preferred), location (medial preferred), and intramuscular course (shorter course preferred) 1, 4

Smoking and obesity are relative contraindications for breast reconstruction due to increased risk of wound healing complications and partial or complete flap failure 5
When postmastectomy radiation therapy is anticipated, autologous tissue reconstruction (DIEP or latissimus dorsi) is preferred over implant-based reconstruction 2, 5
Breast reconstruction does not make detection of local recurrence more difficult 2