Decision between contralateral and ipsilateral DIEP flap harvesting for unilateral breast reconstruction

Deep inferior epigastric artery perforator flap (DIEP/DIEAP) procedure is a common method for breast reconstruction after mastectomy. For unilateral breast reconstruction, harvesting of the flap can be done contralaterally or ipsilaterally. The aim of this study is to demonstrate a possible side difference in quality of abdominal skin perfusion from left to right and its causes, which could have implications on our selection of flap harvesting side, operating time, and flap design itself. We performed thermographic imaging after induced hypothermia of the abdominal skin in 17 females to evaluate the quality of blood supply to each side of the abdominal wall. Additionally, we examined the diameter of the deep inferior epigastric artery, whether there is a difference in size correlating to the quality of blood supply of each side. Evaluation of our pre-operative thermographic imaging method was performed in four patients which underwent unilateral DIEP flap reconstruction regarding reduction of surgery time and assessment of overall outcome. Every subject showed a dominant side of perfusion (greater area of perfusion after set time). Furthermore, we discovered a side difference between left and right diameter of the deep inferior epigastric artery in each patient (0.2-mm mean difference; p = 0.0002). The rewarming process of the abdominal skin was faster (16 out of 17 subjects; 94.1%) (greater area of rewarming after set time) on the side with the greater diameter deep inferior epigastric artery. In our DIEP patients using thermographic imaging of the abdominal skin, we only performed perforator dissection on the preferable side. The consequence was a reduction in operating time of 25 minutes compared to careful dissection of both sides. None of our patients showed complications such as wound-healing disorders. Thermographic assessment of the abdominal skin after hypothermia is easy to conduct and gives reproducible information about different areas of skin perfusion quality. The difference in rewarming speed from left to right is thought to be due to a larger diameter deep inferior epigastric artery, which translates into a superior perfusion, but does not necessarily correlate with the size of the perforators itself. The presented technique offers the potential to improve outcome, especially by lowering perfusion-related complications and reducing operation time by fast dissection of the non-dominant side while carefully dissecting the area of interest with fast thermographic rewarming results, and must therefore be investigated in future studies by measuring objective outcome results. Level of Evidence: Level III, risk/prognostic