Buried Autologous Breast Reconstruction: Outcomes and Technical Considerations

Abstract

The purpose of this study is to compare outcomes in patients undergoing buried and non-buried free flaps for breast reconstruction, in addition to evaluating the safety and reliability of venous flow couplers. A retrospective review was performed of all patients undergoing free flap breast reconstruction between 2013 and 2023. The primary outcomes were free flap failure, complications and the number of procedures required to complete the reconstructive journey. A total of 322 flaps were performed in 254 consecutive patients, with 47.5% (n = 153) being buried and 52.0% (n = 169) being non-buried reconstructions. The most common flap of choice being deep inferior epigastric artery perforator flaps (81.9%) followed by profunda artery perforator flaps (14.3%). There was no significant difference between the two groups in complications, including flap failure (buried 2.0% vs. non-buried 1.8% p = 0.902). There was a significant reduction in the number of procedures required to complete the reconstructive journey, with 52.2% (n = 59) of patients undergoing single-stage breast reconstruction in the buried group compared with only 25.5% (n = 36) in the non-buried group (p < 0.001). Two (0.6%) patients experienced a false negative in which the signal of the flow coupler was lost but the flap was perfused during re-exploration. No flap losses occurred without being identified in advance by a loss of audible venous flow signal. Buried free flap breast reconstruction is safe and requires fewer operations to complete patients' reconstructive journey. Flow couplers are a safe and effective method of monitoring buried free flaps in breast reconstruction.

Keywords: autologous; breast reconstruction; buried; single stage; venous flow coupler.

Figure 1

Left NSM with an IMF incision; immediate buried DIEP.

Figure 2

Bilateral NSM with Wise pattern skin excision; nipple preserved on inferior dermal pedicle; immediate buried DIEP.

Figure 3

Bilateral skin reducing mastectomy with Wise pattern excision; immediate buried DIEP flap.

Figure 4

Delayed reconstruction of right breast, removal of implant and exchange for stacked PAPs with skin paddle due to inadequate skin envelope; subsequent lipofilling and nipple reconstruction with local flap.

Figure 5

Our algorithm for the approach to mastectomy and flap inset.

Figure 6

Reinsertion of flow coupler wire into the dock post-anastomosis.

Figure 7

External coupler wire secured with mesh/glue Prineo™.

Figure 8

Proportion of buried vs. non-buried flaps over time.