Mythbusting the DIEP Flap and An Introduction to the Abdominal Perforator Exchange (APEX) Breast Reconstruction Technique: A Single-Surgeon Retrospective Review

Background: Anatomic variations in perforator arrangement may impair the surgeon's ability to effectively avoid rectus muscle transection without impairing flap perfusion in the DIEP flap. Methods: A single surgeon's experience was reviewed with consecutive patients undergoing bilateral abdominal perforator flap breast reconstruction over 6 years, incorporating flap standardization, pedicle disassembly, and algorithmic vascular rerouting when necessary. Unilateral reconstructions were excluded to allow for uniform comparison of operative times and donor site outcomes. 364 flaps in 182 patients were analyzed. Operative details, and conversion rates from DIEP to APEX arms of the algorithm were collected. Patients with standardized DIEP flaps served as the controlling comparison group and outcomes were compared to those who underwent "APEX" (Abdominal Perforator Exchange) conversion. Results: APEX conversion rate from planned DIEP was 41.5%. Mean additional operative time to employ APEX pedicle disassembly was 34 minutes per flap. Early postsurgical complications were of low incidence and similar among the groups. 1 DIEP flap failed and there were no APEX failures. 1 abdominal bulge occurred in the DIEP group. There were no abdominal hernias in either group. Fat necrosis rates (2.4% APEX/3.4%DIEP) were significantly lower than that historically reported for both TRAM and DIEP flaps. Conclusions: This study revealed no added risk when employing pedicle disassembly to spare muscle/nerve structure during abdominal perforator flap harvest. Abdominal bulge/hernia was nearly completely eliminated. Fat necrosis rates were extremely low, suggesting benefit to pedicle disassembly and vascular routing exchange when required. This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. Financial Disclosure Statement: None of the authors has a financial interest in any of the products, devices, or drugs mentioned in this manuscript. No funding was received for this article. Presented at: The 4th Annual London Breast Meeting, Royal College of Physicians Regents Park, London, UK September 8, 2017 and the American Society for Reconstructive Microsurgery Annual Scientific Meeting, Phoenix, AZ January 15, 2017. Corresponding Author: Frank J. DellaCroce, MD, FACS, Center For Restorative Breast Surgery, Dept. Plastic Surgery, 1717 St. Charles Avenue, New Orleans, LA 70130, Fax: (504) 899-2700, Phone: (504) 899-2800, Email: fjdellacroce@gmail.com / drd@breastcenter.com ©2019American Society of Plastic Surgeons

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