Optimizing Perforator Selection: A Multivariable Analysis of Predictors for Fat Necrosis and Abdominal Morbidity in DIEP Flap Breast Reconstruction

Introduction: This study aims to elucidate the important predicting factors for fat necrosis and abdominal morbidity in the patient undergoing DIEP flap reconstruction. Methods: Retrospective review of 866 free-flap breast reconstructions performed at one institution from 2010-2016. 28 potential predictors were included in multivariable analyses to control for possible confounding interactions. Results: 409 total DIEA perforator flaps were included in our statistical analysis. 14.4% had flap fat necrosis, 21.3% had an abdominal wound or complication, and 6% had an abdominal bulge or hernia. Analysis showed an increase in the odds of fat necrosis with increasing flap weight (OR 1.002 per 1g increase, p-value=. 0002). A decrease in the odds of fat necrosis was seen with lateral row (OR .29, p-value=. 001) and both-row perforator flaps (OR .21, p-value=. 001), if ICG angiography was utilized (OR .46, p-value=. 04), and with increasing total flow rate of the flap (OR .62 per 1 mm/s increase, p-value= .05). Increased odds of abdominal bulge or hernia were seen with lateral or both row perforators (OR 3.21, p-value=. 05) vs. medial row perforator based flaps, and with patients whom had an abdominal wound post-operatively (OR 2.59, p-value=. 05). Conclusions: Our results suggest that utilizing larger caliber perforators and perforators from the lateral row alone, or in addition to medial row perforators, can decrease fat necrosis rather than by simply harvesting more perforators alone. However, lateral and both row perforator flaps come at the cost of increasing abdominal bulge rates. Financial Disclosure: The authors have no commercial or financial associations related to the submitted manuscript, and no commercial or financial conflicts of interest. No funding was received for the performance of this research of production of the manuscript. Acknowledgements: We would like to thank the expedient and accurate work of Hong Zhu, Ph.D. and Jingsheng Yan of the Division of Biostatistics at the Department of Clinical Sciences & Simmons Comprehensive Cancer Center at UT Southwestern Medical Center Corresponding Author: Nicholas Haddock, M.D., UT Southwestern Medical Center, 1801 Inwood Road, Dallas, Texas, 75390, Phone: (214) 645-2353, Email: nicholas.haddock@utsouthwestern.edu ©2018American Society of Plastic Surgeons

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