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© 2015 Plastic and Aesthetic Research | Published by Wolters Kluwer ‑ Medknow	 311
Plastic and Aesthetic Research
INTRODUCTION
Over the past decade, there has been an increase in
breast reconstruction among women who have previously
had liposuction.[1]
Raising a perforator flap is generally
contraindicated after abdominal liposuction due to
possible damage of the perforators that supply the
flap’s vascularity.[2]
Numerous articles have already
demonstrated successful breast reconstruction with a
transverse rectus abdominis myocutaneous flap after
liposuction; however, there is a paucity of data on
breast reconstruction using a deep inferior epigastric
perforator (DIEP) flap after liposuction.[3‑6]
Our experience
Free deep inferior epigastric perforator flap
after abdominal liposuction: reconsidering
a contraindication
Peter James Mankowski, Jonathan Kanevsky, Anne‑Sophie Lessard, Teanoosh Zadeh
Division of Plastic and Reconstructive Surgery, McGill University Health Centre, Montreal, Quebec H3G 1B3, Canada.
Address for correspondence: Mr. Peter James Mankowski, Division of Plastic and Reconstructive Surgery, McGill University Health Centre,
Montreal, Quebec H3G 1B3, Canada. E‑mail: peter.mankowski@mail.mcgill.ca
ABSTRACT
Autologous breast reconstruction with perforators has been previously avoided in tissues that have
undergone liposuction. We present a case series and literature review of breast reconstruction with deep
inferior epigastric perforator (DIEP) flaps after abdominal wall liposuction. An MEDLINE search was
performed for all relevant articles describing breast reconstruction with DIEP flap technique following
the abdominal wall liposuction. Key search words used included “DIEP”, “DIEAP”, “deep inferior
epigastric perforator”, “liposuction” and “free flap”. All published data on the topic from 1965 to
December 2014 were reviewed. Articles were assessed for reports of clinical cases, complications, age,
liposuction amount, time since liposuction and number of perforators for comparison. We have also
presented 2 patients who underwent a DIEP procedure with a previous history of liposuction. Eight
cases of autologous breast reconstruction using a DIEP flap after liposuction were identified in the
literature in addition to the presented cases. The preoperative and postoperative course was uneventful
in all cases except one patient who had a mild cellulitis managed with antibiotics and a second patient
with a drainable hematoma. The average age was 52 years ± 6.4 years old, one perforator was used in
all cases except one where 2 were used, and the average amount of total liposuction was 1,084 mL. No
major complications were reported. Previous liposuction is not an absolute contraindication for free‑flap
breast reconstruction. Preoperative management should include evaluation of suitable perforators by
duplex ultrasound or computed tomography angiography. Larger case series are needed to better
understand the safety of perforator flaps after liposuction.
Key words:
Breast reconstruction, deep inferior epigastric perforator, flap, liposuction
Review Article
How to cite this article: Mankowski PJ, Kanevsky J, Lessard AS,
Zadeh T. Free deep inferior epigastric perforator flap after abdominal
liposuction: reconsidering a contraindication. Plast Aesthet Res
2015;2:311-4.
Received: 19-07-2015; Accepted: 29-09-2015
This is an open access article distributed under the terms of the Creative Commons
Attribution‑NonCommercial‑ShareAlike 3.0 License, which allows others to remix,
tweak, and build upon the work non‑commercially, as long as the author is credited
and the new creations are licensed under the identical terms.
For reprints contact: reprints@medknow.com
Access this article online
Quick Response Code:
Website:
www.parjournal.net
DOI:
10.4103/2347-9264.169504
Plast Aesthet Res || Vol 2 || Issue 6 || Nov 12, 2015312
of breast reconstruction with DIEP flap after abdominal
wall liposuction will be demonstrated in addition to a
literature review.
METHODS
An MEDLINE search was performed for all relevant
articles describing the breast reconstruction with DIEP
flap technique following abdominal wall liposuction. This
study includes all published data on the topic from 1965
to December 2014. The PubMed database of the National
Center for Biotechnology Information, National Library of
Medicine (Bethesda, Maryland, USA), was used to collect
reports using the keywords “DIEP”, “DIEAP”, “deep inferior
epigastric perforator”, “liposuction” and “free flap”. All
articles were reviewed for reports of clinical cases including
complications, age, liposuction amount, time since
liposuction and the number of perforators for comparison.
RESULTS
A total of 8 cases of autologous breast reconstruction
using a DIEP flap after liposuction were identified in
the literature review in addition to the 2 cases we
present here. A study by De Frene et al.[7]
describes five
consecutive cases, and Jandali et al.[1]
reports one case.
In addition, Farid et al.[8]
reported 2 cases involving DIEP
flap breast reconstruction after multiple liposuction
procedures. The results of these studies including our
cases are summarized in Table 1. The preoperative and
postoperative course for all prior liposuction cases was
uneventful except for our 2 patients: one who had a mild
cellulitis that resolved with appropriate therapy without
any compromise of the flap and another who experienced
a hematoma which was subsequently drained. The
average patient age was 52.2 years ± 6.4 years old, and
one perforator was used in all cases except one report
where two were used. Of the reported cases, the average
amount of liposuction collected was 1,084 mL. Two minor
complications out of the total 10 cases were a mild
cellulitis and a postoperative stable hematoma. No major
complications were reported.
Case 1
A 50‑year‑old, nonsmoker, female underwent a left sided
mastectomy for invasive ductal carcinoma. Conventional
abdominal liposuction was performed 5 years before
the original diagnosis of breast cancer. Three years after
the mastectomy, the patient underwent autologous breast
reconstruction with a DIEP flap. The patient was
evaluated preoperatively for suitable perforators by
computed tomography (CT) angiography and duplex
ultrasound. Examination revealed appropriate perforator
vessels and extensive fibrosis throughout the subcutaneous
tissue caused by the previous liposuction. The patient
underwent delayed unilateral breast reconstruction with a
free DIEP flap. The postoperative course was complicated
by a mild cellulitis that was successfully treated with
antibiotics and no damage resulted to the flap [Figure 1].
Case 2
A 59‑year‑old, smoker, female with breast cancer
underwent a right mastectomy in 1998 followed by
implant‑based reconstruction the same year. She later
underwent radiation therapy and subsequently developed
severe capsular contracture [Figure 2]. In 2012, she
underwent right breast capsulectomy and reconstruction
with DIEP flap. Eighteen years earlier, the patient had
undergone conventional abdominal liposuction. The
patient was evaluated preoperatively for suitable
perforators by CT angiography and duplex ultrasound.
Examination revealed appropriate perforator vessels.
Three days following the DIEP flap procedure the patient
developed a hematoma that was evacuated and the
patient had a stable postoperative course without any
flap compromise.
DISCUSSION
Previous literature suggests that harvesting perforator
flaps from liposuctioned donor sites may not necessarily be
a contraindication to free‑flap breast reconstruction.[5,7]
The
largest reported series of DIEP flaps after liposuction was
published by De Frene et al.[7]
with five successful cases
of breast reconstruction. The DIEP flap, introduced by
Itoh and Arai[9]
and Koshima and Soeda[10]
and popularized
by Allen and Treece,[11]
Blondeel and Boeckx,[12]
and
Blondeel[13]
has been described as the most appropriate
way to reconstruct a breast to minimize donor
morbidity.[6,14,15]
The effect of liposuction on a free flap
donor site months or years before flap transfer remains
to be clarified.
Table 1: Summary of studies performing DIEP reconstruction in patients who have had previous liposuction
Study Age Number of perforators Liposuction (mL) Years after liposuction Complications
Jandali et al.[1]
42 2 Not reported 9 None
Farid et al.[8]
57 1 240 + 300 + 300 1.33 None
54 1 100 to 160 × 5 0.5 None
De Frene et al.[7]
52 1 1,300 4 None
58 1 1,000 11 None
41 1 1,100 9 None
52 1 1,500 6.5 None
57 1 1,200 4 None
Our study 50 1 Not reported 5 Mild cellulitis
59 2 Not reported 18 Hematoma
DIEP: Deep inferior epigastric perforator
Plast Aesthet Res || Vol 2 || Issue 6 || Nov 12, 2015 	 313
Previous literature has shown conflicting evidence regarding
the effect of liposuction on donor tissue, specifically,
perforator vessels. Teimourian and Kroll[16]
reported that
neurovascular bundles remain intact following conventional
liposuction on examination with subcutaneous endoscopy.
However, a study by Ozcan et al.[17]
demonstrated that flap
necrosis is directly related to the number of suction passes
of a cannula accompanied by a vacuum. İnceoğlu et al.[18]
reported a 57.8% decrease in the number of perforators in
abdominal subcutaneous tissue 3 months after liposuction
using duplex ultrasound. Despite the reported decrease in
the number of perforators, Ribuffo et al.[5]
demonstrated
that perforator arteries regenerate up to 40% of their
original diameter after liposuction. This evidence suggests
that the liposuction technique may influence the degree
to which perforator vessels are damaged and the outcome
of the flap.
It should be possible to minimize patient complications
associated with free‑flap breast reconstruction after
liposuction through modification of the initial liposuction
procedure and decreasing trauma to perforators during
liposuction. The variability in a number of perforators
after liposuction is likely related to factors such as the
cannula used, the number of passes, strength of suction
and operator force and technique. An ultrasound‑assisted
liposuction technique described by Zocchi[19]
showed less
damage to neurovascular structures. However, these findings
were later opposed by a study which compared conventional
versus ultrasonic liposuction.[2]
Salgarello et al.[20]
suggest
employing a superficial subdermal liposuction technique to
maintain perforator viability. Overall, a refined technique
or protocol for liposuction in future free flap donor areas
may improve patient outcome.
There are inherent difficulties in choosing when to use a
technique to maximize perforator viability. For example,
it is not possible to predict which patients will require
autologous breast reconstruction with a free flap at the
time of abdominal liposuction. Furthermore, patients
may have breast reconstruction with a different surgeon
than the one who performed the liposuction, creating
a challenge for the surgeon to predict the adequacy
of perforators in the future donor site. As noted by
Wes et al.,[21]
breast reconstructive in the context of
previous abdominal surgery therefore requires a thorough
preoperative evaluation to prevent flap morbidity.
Specifically in the context of liposuction, duplex ultrasound
and CT angiography will help identify perforator viability to
reduce procedural complications. The use of color duplex
examination as a preoperative guide is reported to have a
true‑positive rate of 96.2% and a positive predictive value
of 100% in the hands of an experienced sonographer.[22]
The use of CT angiography as a preoperative methodology
was reinforced by both Bank et al.[23]
and Rozen et al.[24]
to confirm perforator presence and communication for
facilitating DIEP flap paddle design in postabdominal
procedure patients. Rozen et al.[24]
highlighted the
benefit of preoperative CT flap design as a method for
identifying perforators resulted from neovascularization
offering additional possibilities for DIEP harvesting. Other
techniques such as flap perfusion mapping may be useful
when the surgeon needs to know the integrity of vessels
that are too small to image with standard angiographic
techniques preoperatively.[25]
In addition, Masia et al.[26]
described multidetector‑row CT, an imaging modality that
allows for interpretation of a virtual anatomic dissection
in three dimensions with very high spatial resolution.
Intraoperative laser angiography using the SPY system
has been shown to be beneficial for assessing tissue
perfusion during flap elevation.[27]
Application of SPY laser
angiography decreases the incidence skip necrosis in
postmastectomy reconstruction and the rate of reoperation
due to of perfusion related complications.[28]
Finally,
Farid et al.[8]
prefer MR angiography to CT angiography
to avoid reliance on intravenous contrast and to reduce
patient exposure to radiation. Appropriate application
of these techniques for perforator evaluation including
CT, ultrasound, or perfusion mapping may improve the
outcome of patients undergoing DIEP after abdominal
liposuction
CONCLUSION
We have demonstrated two cases, in addition to the previously
reported literature that suggest previous conventional
liposuction is not an absolute contraindication for free‑flap
breast reconstruction. Preoperative management of the
patient should include thorough evaluation of suitable
Figure 1: Case 1, patient before (a) and after (b), deep inferior epigastric
perforator procedure with evidence of mild cellulitis surrounding the
flap; (c) patient at 2 years follow-up after additional nipple reconstructive
produces and extensive weight loss
ba
c
Figure 2: Case 2, (a) Patient prior to breast reconstruction with severe
capsular contracture; (b) after DIEP flap procedure. DIEP: Deep inferior
epigastric perforator
ba
Plast Aesthet Res || Vol 2 || Issue 6 || Nov 12, 2015314
perforators by duplex ultrasound or CT angiography. In
patients with history of liposuction to the lower abdomen,
a classification system would be of clinical utility in
guiding the selection of the ideal technique for breast
reconstruction. Larger case series are needed to better
understand the safety of perforator flaps after liposuction.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
REFERENCES
1.	 Jandali S, Nelson JA, Wu LC, Serletti JM. Free transverse rectus abdominis
myocutaneous flap for breast reconstruction in patients with prior abdominal
contouring procedures. J Reconstr Microsurg 2010;26:607‑14.
2.	 Blondeel PN, Derks D, Roche N, Van Landuyt KH, Monstrey SJ. The effect
of ultrasound‑assisted liposuction and conventional liposuction on the
perforator vessels in the lower abdominal wall. Br J Plast Surg 2003;56:266‑71.
3.	 Hess CL, Gartside RL, Ganz JC. TRAM flap breast reconstruction after
abdominal liposuction. Ann Plast Surg 2004;53:166‑9.
4.	 Karanas YL, Santoro TD, Da Lio AL, Shaw WW. Free TRAM flap
breast reconstruction after abdominal liposuction. Plast Reconstr Surg
2003;112:1851‑4.
5.	 Ribuffo D, Marcellino M, Barnett GR, Houseman ND, Scuderi N. Breast
reconstruction with abdominal flaps after abdominoplasties. Plast Reconstr Surg
2001;108:1604‑8.
6.	 Tachi M, Yamada A. Choice of flaps for breast reconstruction. Int J Clin Oncol
2005;10:289‑97.
7.	 De Frene B, Van Landuyt K, Hamdi M, Blondeel P, Roche N, Voet D,
Monstrey S. Free DIEAP and SGAP flap breast reconstruction after
abdominal/gluteal liposuction. J Plast Reconstr Aesthet Surg 2006;59:1031‑6.
8.	 Farid M, Nicholson S, Kotwal A, Akali A. DIEP breast reconstruction following
multiple abdominal liposuction procedures. Eplasty 2014;14:e47.
9.	 Itoh Y, Arai K. The deep inferior epigastric artery free skin flap: anatomic
study and clinical application. Plast Reconstr Surg 1993;91:853‑63.
10.	 Koshima I, Soeda S. Inferior epigastric artery skin flaps without rectus
abdominis muscle. Br J Plast Surg 1989;42:645‑8.
11.	 Allen  RJ, Treece  P. Deep inferior epigastric perforator flap for breast
reconstruction. Ann Plast Surg 1994;32:32‑8.
12.	 Blondeel PN, Boeckx WD. Refinements in free flap breast reconstruction:
the free bilateral deep inferior epigastric perforator flap anastomosed to the
internal mammary artery. Br J Plast Surg 1994;47:495‑501.
13.	 Blondeel PN. One hundred free DIEP flap breast reconstructions: a personal
experience. Br J Plast Surg 1999;52:104‑11.
14.	 Arnez ZM, Pogorelec D, Planinsek F, Ahcan U. Breast reconstruction by the
free transverse gracilis (TUG) flap. Br J Plast Surg 2004;57:20‑6.
15.	 Hamdi M, Weiler‑Mithoff EM, Webster MH. Deep inferior epigastric
perforator flap in breast reconstruction: experience with the first 50 flaps.
Plast Reconstr Surg 1999;103:86‑95.
16.	 Teimourian B, Kroll SS. Subcutaneous endoscopy in suction lipectomy.
Plast Reconstr Surg 1984;74:708‑11.
17.	 Ozcan G, Shenaq S, Baldwin B, Spira M. The trauma of suction‑assisted
lipectomy cannula on flap circulation in rats. Plast Reconstr Surg 1991;88:250‑8.
18.	 İnceoğlu S, Özdemir H, İnceoğlu F, Demir H, Önal B, Çelebi C. Investigation
of the effect of liposuction on the perforator vessels using color Doppler
ultrasonography. Eur J Plast Surg 1998;21:38‑42.
19.	 Zocchi M. Ultrasonic liposculpturing. Aesthetic Plast Surg 1992;16:287‑98.
20.	 Salgarello M, Barone‑Adesi L, Cina A, Farallo E. The effect of liposuction on
inferior epigastric perforator vessels: a prospective study with color Doppler
sonography. Ann Plast Surg 2005;55:346‑51.
21.	 Wes AM, Cleveland E, Nelson JA, Fischer JP, Kovach SJ, Kanchwala S,
Serletti JM, Wu LC. Do prior abdominal surgeries increase complications
in abdominally based breast reconstructions? Ann Plast Surg 2015;75:526-33.
22.	 Blondeel PN, Beyens G, Verhaeghe R, Van Landuyt K, Tonnard P, Monstrey SJ,
Matton G. Doppler flowmetry in the planning of perforator flaps. Br J Plast Surg
1998;51:202‑9.
23.	 Bank J, Pavone LA, Seitz IA, Roughton MC, Schechter LS. CASE REPORT
case report and review of the literature: deep inferior epigastric perforator
flap for breast reconstruction after abdominal recontouring. Eplasty
2012;12:e52.
24.	 Rozen WM, Whitaker IS, Ting JW, Ang GG, Acosta R. Deep inferior epigastric
artery perforator flap harvest after abdominoplasty with the use of computed
tomographic angiography. Plast Reconstr Surg 2012;129:198e‑200e.
25.	 May JW Jr, Silverman RP, Kaufman JA. Flap perfusion mapping: TRAM flap after
abdominal suction‑assisted lipectomy. Plast Reconstr Surg 1999;104:2278‑81.
26.	 Masia J, Clavero JA, Larranaga JR, Alomar X, Pons G, Serret P.
Multidetector‑row computed tomography in the planning of abdominal
perforator flaps. J Plast Reconstr Aesthet Surg 2006;59:594‑9.
27.	 Gurtner GC, Jones GE, Neligan PC, Newman MI, Phillips BT, Sacks JM,
Zenn MR. Intraoperative laser angiography using the SPY system: review of
the literature and recommendations for use. Ann Surg Innov Res 2013;7:1.
28.	 Duggal CS, Madni T, Losken A. An outcome analysis of intraoperative
angiography for postmastectomy breast reconstruction. Aesthet Surg J
2014;34:61‑5.

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DIEP

  • 1. © 2015 Plastic and Aesthetic Research | Published by Wolters Kluwer ‑ Medknow 311 Plastic and Aesthetic Research INTRODUCTION Over the past decade, there has been an increase in breast reconstruction among women who have previously had liposuction.[1] Raising a perforator flap is generally contraindicated after abdominal liposuction due to possible damage of the perforators that supply the flap’s vascularity.[2] Numerous articles have already demonstrated successful breast reconstruction with a transverse rectus abdominis myocutaneous flap after liposuction; however, there is a paucity of data on breast reconstruction using a deep inferior epigastric perforator (DIEP) flap after liposuction.[3‑6] Our experience Free deep inferior epigastric perforator flap after abdominal liposuction: reconsidering a contraindication Peter James Mankowski, Jonathan Kanevsky, Anne‑Sophie Lessard, Teanoosh Zadeh Division of Plastic and Reconstructive Surgery, McGill University Health Centre, Montreal, Quebec H3G 1B3, Canada. Address for correspondence: Mr. Peter James Mankowski, Division of Plastic and Reconstructive Surgery, McGill University Health Centre, Montreal, Quebec H3G 1B3, Canada. E‑mail: peter.mankowski@mail.mcgill.ca ABSTRACT Autologous breast reconstruction with perforators has been previously avoided in tissues that have undergone liposuction. We present a case series and literature review of breast reconstruction with deep inferior epigastric perforator (DIEP) flaps after abdominal wall liposuction. An MEDLINE search was performed for all relevant articles describing breast reconstruction with DIEP flap technique following the abdominal wall liposuction. Key search words used included “DIEP”, “DIEAP”, “deep inferior epigastric perforator”, “liposuction” and “free flap”. All published data on the topic from 1965 to December 2014 were reviewed. Articles were assessed for reports of clinical cases, complications, age, liposuction amount, time since liposuction and number of perforators for comparison. We have also presented 2 patients who underwent a DIEP procedure with a previous history of liposuction. Eight cases of autologous breast reconstruction using a DIEP flap after liposuction were identified in the literature in addition to the presented cases. The preoperative and postoperative course was uneventful in all cases except one patient who had a mild cellulitis managed with antibiotics and a second patient with a drainable hematoma. The average age was 52 years ± 6.4 years old, one perforator was used in all cases except one where 2 were used, and the average amount of total liposuction was 1,084 mL. No major complications were reported. Previous liposuction is not an absolute contraindication for free‑flap breast reconstruction. Preoperative management should include evaluation of suitable perforators by duplex ultrasound or computed tomography angiography. Larger case series are needed to better understand the safety of perforator flaps after liposuction. Key words: Breast reconstruction, deep inferior epigastric perforator, flap, liposuction Review Article How to cite this article: Mankowski PJ, Kanevsky J, Lessard AS, Zadeh T. Free deep inferior epigastric perforator flap after abdominal liposuction: reconsidering a contraindication. Plast Aesthet Res 2015;2:311-4. Received: 19-07-2015; Accepted: 29-09-2015 This is an open access article distributed under the terms of the Creative Commons Attribution‑NonCommercial‑ShareAlike 3.0 License, which allows others to remix, tweak, and build upon the work non‑commercially, as long as the author is credited and the new creations are licensed under the identical terms. For reprints contact: reprints@medknow.com Access this article online Quick Response Code: Website: www.parjournal.net DOI: 10.4103/2347-9264.169504
  • 2. Plast Aesthet Res || Vol 2 || Issue 6 || Nov 12, 2015312 of breast reconstruction with DIEP flap after abdominal wall liposuction will be demonstrated in addition to a literature review. METHODS An MEDLINE search was performed for all relevant articles describing the breast reconstruction with DIEP flap technique following abdominal wall liposuction. This study includes all published data on the topic from 1965 to December 2014. The PubMed database of the National Center for Biotechnology Information, National Library of Medicine (Bethesda, Maryland, USA), was used to collect reports using the keywords “DIEP”, “DIEAP”, “deep inferior epigastric perforator”, “liposuction” and “free flap”. All articles were reviewed for reports of clinical cases including complications, age, liposuction amount, time since liposuction and the number of perforators for comparison. RESULTS A total of 8 cases of autologous breast reconstruction using a DIEP flap after liposuction were identified in the literature review in addition to the 2 cases we present here. A study by De Frene et al.[7] describes five consecutive cases, and Jandali et al.[1] reports one case. In addition, Farid et al.[8] reported 2 cases involving DIEP flap breast reconstruction after multiple liposuction procedures. The results of these studies including our cases are summarized in Table 1. The preoperative and postoperative course for all prior liposuction cases was uneventful except for our 2 patients: one who had a mild cellulitis that resolved with appropriate therapy without any compromise of the flap and another who experienced a hematoma which was subsequently drained. The average patient age was 52.2 years ± 6.4 years old, and one perforator was used in all cases except one report where two were used. Of the reported cases, the average amount of liposuction collected was 1,084 mL. Two minor complications out of the total 10 cases were a mild cellulitis and a postoperative stable hematoma. No major complications were reported. Case 1 A 50‑year‑old, nonsmoker, female underwent a left sided mastectomy for invasive ductal carcinoma. Conventional abdominal liposuction was performed 5 years before the original diagnosis of breast cancer. Three years after the mastectomy, the patient underwent autologous breast reconstruction with a DIEP flap. The patient was evaluated preoperatively for suitable perforators by computed tomography (CT) angiography and duplex ultrasound. Examination revealed appropriate perforator vessels and extensive fibrosis throughout the subcutaneous tissue caused by the previous liposuction. The patient underwent delayed unilateral breast reconstruction with a free DIEP flap. The postoperative course was complicated by a mild cellulitis that was successfully treated with antibiotics and no damage resulted to the flap [Figure 1]. Case 2 A 59‑year‑old, smoker, female with breast cancer underwent a right mastectomy in 1998 followed by implant‑based reconstruction the same year. She later underwent radiation therapy and subsequently developed severe capsular contracture [Figure 2]. In 2012, she underwent right breast capsulectomy and reconstruction with DIEP flap. Eighteen years earlier, the patient had undergone conventional abdominal liposuction. The patient was evaluated preoperatively for suitable perforators by CT angiography and duplex ultrasound. Examination revealed appropriate perforator vessels. Three days following the DIEP flap procedure the patient developed a hematoma that was evacuated and the patient had a stable postoperative course without any flap compromise. DISCUSSION Previous literature suggests that harvesting perforator flaps from liposuctioned donor sites may not necessarily be a contraindication to free‑flap breast reconstruction.[5,7] The largest reported series of DIEP flaps after liposuction was published by De Frene et al.[7] with five successful cases of breast reconstruction. The DIEP flap, introduced by Itoh and Arai[9] and Koshima and Soeda[10] and popularized by Allen and Treece,[11] Blondeel and Boeckx,[12] and Blondeel[13] has been described as the most appropriate way to reconstruct a breast to minimize donor morbidity.[6,14,15] The effect of liposuction on a free flap donor site months or years before flap transfer remains to be clarified. Table 1: Summary of studies performing DIEP reconstruction in patients who have had previous liposuction Study Age Number of perforators Liposuction (mL) Years after liposuction Complications Jandali et al.[1] 42 2 Not reported 9 None Farid et al.[8] 57 1 240 + 300 + 300 1.33 None 54 1 100 to 160 × 5 0.5 None De Frene et al.[7] 52 1 1,300 4 None 58 1 1,000 11 None 41 1 1,100 9 None 52 1 1,500 6.5 None 57 1 1,200 4 None Our study 50 1 Not reported 5 Mild cellulitis 59 2 Not reported 18 Hematoma DIEP: Deep inferior epigastric perforator
  • 3. Plast Aesthet Res || Vol 2 || Issue 6 || Nov 12, 2015 313 Previous literature has shown conflicting evidence regarding the effect of liposuction on donor tissue, specifically, perforator vessels. Teimourian and Kroll[16] reported that neurovascular bundles remain intact following conventional liposuction on examination with subcutaneous endoscopy. However, a study by Ozcan et al.[17] demonstrated that flap necrosis is directly related to the number of suction passes of a cannula accompanied by a vacuum. İnceoğlu et al.[18] reported a 57.8% decrease in the number of perforators in abdominal subcutaneous tissue 3 months after liposuction using duplex ultrasound. Despite the reported decrease in the number of perforators, Ribuffo et al.[5] demonstrated that perforator arteries regenerate up to 40% of their original diameter after liposuction. This evidence suggests that the liposuction technique may influence the degree to which perforator vessels are damaged and the outcome of the flap. It should be possible to minimize patient complications associated with free‑flap breast reconstruction after liposuction through modification of the initial liposuction procedure and decreasing trauma to perforators during liposuction. The variability in a number of perforators after liposuction is likely related to factors such as the cannula used, the number of passes, strength of suction and operator force and technique. An ultrasound‑assisted liposuction technique described by Zocchi[19] showed less damage to neurovascular structures. However, these findings were later opposed by a study which compared conventional versus ultrasonic liposuction.[2] Salgarello et al.[20] suggest employing a superficial subdermal liposuction technique to maintain perforator viability. Overall, a refined technique or protocol for liposuction in future free flap donor areas may improve patient outcome. There are inherent difficulties in choosing when to use a technique to maximize perforator viability. For example, it is not possible to predict which patients will require autologous breast reconstruction with a free flap at the time of abdominal liposuction. Furthermore, patients may have breast reconstruction with a different surgeon than the one who performed the liposuction, creating a challenge for the surgeon to predict the adequacy of perforators in the future donor site. As noted by Wes et al.,[21] breast reconstructive in the context of previous abdominal surgery therefore requires a thorough preoperative evaluation to prevent flap morbidity. Specifically in the context of liposuction, duplex ultrasound and CT angiography will help identify perforator viability to reduce procedural complications. The use of color duplex examination as a preoperative guide is reported to have a true‑positive rate of 96.2% and a positive predictive value of 100% in the hands of an experienced sonographer.[22] The use of CT angiography as a preoperative methodology was reinforced by both Bank et al.[23] and Rozen et al.[24] to confirm perforator presence and communication for facilitating DIEP flap paddle design in postabdominal procedure patients. Rozen et al.[24] highlighted the benefit of preoperative CT flap design as a method for identifying perforators resulted from neovascularization offering additional possibilities for DIEP harvesting. Other techniques such as flap perfusion mapping may be useful when the surgeon needs to know the integrity of vessels that are too small to image with standard angiographic techniques preoperatively.[25] In addition, Masia et al.[26] described multidetector‑row CT, an imaging modality that allows for interpretation of a virtual anatomic dissection in three dimensions with very high spatial resolution. Intraoperative laser angiography using the SPY system has been shown to be beneficial for assessing tissue perfusion during flap elevation.[27] Application of SPY laser angiography decreases the incidence skip necrosis in postmastectomy reconstruction and the rate of reoperation due to of perfusion related complications.[28] Finally, Farid et al.[8] prefer MR angiography to CT angiography to avoid reliance on intravenous contrast and to reduce patient exposure to radiation. Appropriate application of these techniques for perforator evaluation including CT, ultrasound, or perfusion mapping may improve the outcome of patients undergoing DIEP after abdominal liposuction CONCLUSION We have demonstrated two cases, in addition to the previously reported literature that suggest previous conventional liposuction is not an absolute contraindication for free‑flap breast reconstruction. Preoperative management of the patient should include thorough evaluation of suitable Figure 1: Case 1, patient before (a) and after (b), deep inferior epigastric perforator procedure with evidence of mild cellulitis surrounding the flap; (c) patient at 2 years follow-up after additional nipple reconstructive produces and extensive weight loss ba c Figure 2: Case 2, (a) Patient prior to breast reconstruction with severe capsular contracture; (b) after DIEP flap procedure. DIEP: Deep inferior epigastric perforator ba
  • 4. Plast Aesthet Res || Vol 2 || Issue 6 || Nov 12, 2015314 perforators by duplex ultrasound or CT angiography. In patients with history of liposuction to the lower abdomen, a classification system would be of clinical utility in guiding the selection of the ideal technique for breast reconstruction. Larger case series are needed to better understand the safety of perforator flaps after liposuction. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest. REFERENCES 1. Jandali S, Nelson JA, Wu LC, Serletti JM. Free transverse rectus abdominis myocutaneous flap for breast reconstruction in patients with prior abdominal contouring procedures. J Reconstr Microsurg 2010;26:607‑14. 2. Blondeel PN, Derks D, Roche N, Van Landuyt KH, Monstrey SJ. The effect of ultrasound‑assisted liposuction and conventional liposuction on the perforator vessels in the lower abdominal wall. Br J Plast Surg 2003;56:266‑71. 3. Hess CL, Gartside RL, Ganz JC. TRAM flap breast reconstruction after abdominal liposuction. Ann Plast Surg 2004;53:166‑9. 4. Karanas YL, Santoro TD, Da Lio AL, Shaw WW. Free TRAM flap breast reconstruction after abdominal liposuction. Plast Reconstr Surg 2003;112:1851‑4. 5. Ribuffo D, Marcellino M, Barnett GR, Houseman ND, Scuderi N. Breast reconstruction with abdominal flaps after abdominoplasties. Plast Reconstr Surg 2001;108:1604‑8. 6. Tachi M, Yamada A. Choice of flaps for breast reconstruction. Int J Clin Oncol 2005;10:289‑97. 7. De Frene B, Van Landuyt K, Hamdi M, Blondeel P, Roche N, Voet D, Monstrey S. Free DIEAP and SGAP flap breast reconstruction after abdominal/gluteal liposuction. J Plast Reconstr Aesthet Surg 2006;59:1031‑6. 8. Farid M, Nicholson S, Kotwal A, Akali A. DIEP breast reconstruction following multiple abdominal liposuction procedures. Eplasty 2014;14:e47. 9. Itoh Y, Arai K. The deep inferior epigastric artery free skin flap: anatomic study and clinical application. Plast Reconstr Surg 1993;91:853‑63. 10. Koshima I, Soeda S. Inferior epigastric artery skin flaps without rectus abdominis muscle. Br J Plast Surg 1989;42:645‑8. 11. Allen  RJ, Treece  P. Deep inferior epigastric perforator flap for breast reconstruction. Ann Plast Surg 1994;32:32‑8. 12. Blondeel PN, Boeckx WD. Refinements in free flap breast reconstruction: the free bilateral deep inferior epigastric perforator flap anastomosed to the internal mammary artery. Br J Plast Surg 1994;47:495‑501. 13. Blondeel PN. One hundred free DIEP flap breast reconstructions: a personal experience. Br J Plast Surg 1999;52:104‑11. 14. Arnez ZM, Pogorelec D, Planinsek F, Ahcan U. Breast reconstruction by the free transverse gracilis (TUG) flap. Br J Plast Surg 2004;57:20‑6. 15. Hamdi M, Weiler‑Mithoff EM, Webster MH. Deep inferior epigastric perforator flap in breast reconstruction: experience with the first 50 flaps. Plast Reconstr Surg 1999;103:86‑95. 16. Teimourian B, Kroll SS. Subcutaneous endoscopy in suction lipectomy. Plast Reconstr Surg 1984;74:708‑11. 17. Ozcan G, Shenaq S, Baldwin B, Spira M. The trauma of suction‑assisted lipectomy cannula on flap circulation in rats. Plast Reconstr Surg 1991;88:250‑8. 18. İnceoğlu S, Özdemir H, İnceoğlu F, Demir H, Önal B, Çelebi C. Investigation of the effect of liposuction on the perforator vessels using color Doppler ultrasonography. Eur J Plast Surg 1998;21:38‑42. 19. Zocchi M. Ultrasonic liposculpturing. Aesthetic Plast Surg 1992;16:287‑98. 20. Salgarello M, Barone‑Adesi L, Cina A, Farallo E. The effect of liposuction on inferior epigastric perforator vessels: a prospective study with color Doppler sonography. Ann Plast Surg 2005;55:346‑51. 21. Wes AM, Cleveland E, Nelson JA, Fischer JP, Kovach SJ, Kanchwala S, Serletti JM, Wu LC. Do prior abdominal surgeries increase complications in abdominally based breast reconstructions? Ann Plast Surg 2015;75:526-33. 22. Blondeel PN, Beyens G, Verhaeghe R, Van Landuyt K, Tonnard P, Monstrey SJ, Matton G. Doppler flowmetry in the planning of perforator flaps. Br J Plast Surg 1998;51:202‑9. 23. Bank J, Pavone LA, Seitz IA, Roughton MC, Schechter LS. CASE REPORT case report and review of the literature: deep inferior epigastric perforator flap for breast reconstruction after abdominal recontouring. Eplasty 2012;12:e52. 24. Rozen WM, Whitaker IS, Ting JW, Ang GG, Acosta R. Deep inferior epigastric artery perforator flap harvest after abdominoplasty with the use of computed tomographic angiography. Plast Reconstr Surg 2012;129:198e‑200e. 25. May JW Jr, Silverman RP, Kaufman JA. Flap perfusion mapping: TRAM flap after abdominal suction‑assisted lipectomy. Plast Reconstr Surg 1999;104:2278‑81. 26. Masia J, Clavero JA, Larranaga JR, Alomar X, Pons G, Serret P. Multidetector‑row computed tomography in the planning of abdominal perforator flaps. J Plast Reconstr Aesthet Surg 2006;59:594‑9. 27. Gurtner GC, Jones GE, Neligan PC, Newman MI, Phillips BT, Sacks JM, Zenn MR. Intraoperative laser angiography using the SPY system: review of the literature and recommendations for use. Ann Surg Innov Res 2013;7:1. 28. Duggal CS, Madni T, Losken A. An outcome analysis of intraoperative angiography for postmastectomy breast reconstruction. Aesthet Surg J 2014;34:61‑5.