Optimizing Intraflap Anastomosis of Conjoined Bilateral DIEP Flap for Breast Reconstruction: Planning, Execution, and Outcomes in 201 Patients

BACKGROUND: Conjoined bilateral deep inferior epigastric perforator (DIEP) flap with intraflap anastomosis is an efficient approach for breast reconstruction, enabling the use of almost the entire abdominal tissue. Variations in bilateral deep inferior epigastric artery (DIEA) anatomy may make it challenging to apply this technique consistently. This study aimed to derive optimal strategies for achieving reliable conjoined bilateral DIEP flap with intraflap anastomosis universally. METHODS: For all consecutive patients undergoing conjoined bilateral DIEP flap-based breast reconstruction from 2009 to 2023, preoperative planning and intraoperative execution for the pedicle configurations were reviewed. Their postoperative outcomes were evaluated. RESULTS: In total, 201 patients were included, with no cases requiring conversion to extraflap anastomosis. In preoperative planning, candidates for recipient vessels for intraflap anastomosis were typically selected on the basis of DIEA branching patterns, identified through computed tomographic angiography: type 1 (single trunk) prioritizing the superior continuation, type 2 (2 main trunks) considering a side branch, and type 3 (3 main trunks) favoring the first bifurcating branch. Comparing candidates from bilateral DIEA, the primary pedicle was determined, providing larger recipient vessels. Most cases followed the planned approach smoothly; however, 28 required intraoperative changes, mostly aimed at securing larger recipients by changing the primary pedicle or harvesting more caudally located perforators to obtain larger superior continuations. Four perfusion-related complications developed, which were resolved successfully without flap failure. CONCLUSION: The authors' results suggest an efficient strategy for securing a reliable recipient vessel, tailored to patient anatomy, in conjoined bilateral DIEP flap breast reconstruction with intraflap anastomosis, leading to achieving optimal outcomes. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.