No skin paddle, no problem: burying DIEP flaps in the immediate setting is safe in select patient populations.

BACKGROUND: Because immediately burying a free flap forgoes the incorporation of a monitoring skin paddle it may be associated with an increased risk of flap loss or other perfusion-related complications, such as fat necrosis. We hypothesized that fully de-epithelialized breast free flaps were not associated with an increased complication rate, reduced the need for future revision surgery, and had superior patient reported outcomes.

METHODS: A single institution retrospective review of 206 DIEP flaps in 142 patients was performed between June 2016 and September 2021. Flaps were grouped into buried or non-buried categories based on the absence or presence of a monitoring paddle. Patient reported outcomes were assessed postoperatively using the BREAST Q breast reconstruction module. Electronic medical record data included demographics, comorbidities, flap characteristics, complications, and revision surgery.

RESULTS: The buried flap patients (N= 46) had a lower median BMI (26.9 vs 30.3, p=0.04) and a lower rate of hypertension (19.5% vs 37.5%, p=0.04) compared to non-buried flap patients (N=160). Burying flaps was more likely in an immediate or a delayed-immediate fashion compared to delayed reconstruction (p=0.009). There was one flap loss in the non-buried group; complication rates were similar. There was a significantly greater revision rate in the non-buried flap patients (92% vs 70%; p=0.002). Buried flap patients exhibited a greater satisfaction with breasts (84.5  13.4 vs. 73.9  21.4; p=0.04) and sexual satisfaction (73.1 22.4 vs. 53.7  29.7; p=0.01) compared to non-buried flap patients.

CONCLUSION: Burying breast free flaps in appropriately selected patients does not appear to have a higher complication rate when compared to flaps with an externalized monitoring paddle. Furthermore, this modification may be associated with a better immediate aesthetic outcome and improved patient satisfaction, as evidenced by a lower rate of revision surgery and superior Breast Q scores amongst buried DIEP flaps.