Revision Rates of Left and Right Breast Reconstruction Differ With DIEP Flaps: Implications for Inexperienced Surgeons

Abstract

Background: The internal mammary system provides the recipient vessel of choice in free autologous tissue breast reconstruction. However, left internal mammary veins (IMVs) are smaller than right IMVs, thus raising questions about their reliability. Here we analyzed right and left breast deep inferior epigastric perforator (DIEP) flap reconstruction performed by an experienced versus less experienced surgeon and hypothesized that less experienced surgeons might encounter difficulty in cases of smaller left IMVs.

Methods: We respectively reviewed the charts of 714 DIEP flap breast reconstructions performed by an experienced surgeon (>15 years' DIEP flap experience) and 231 performed by a relatively inexperienced surgeon (<4 years' DIEP flap experience). Reconstructions requiring microvascular revisions were compared with nonrevision controls, and left-side reconstructions were compared with right-side controls.

Results: Preoperative risk factors were not significantly different between the left and right cohorts for either surgeon. The experienced surgeon performed 17 microvascular revisions (2.4%), including 9 left (52.9%) and 8 right (47.1%). The less experienced surgeon performed 7 microvascular revisions (3.0%), all left. The left- and right-side revision rates were 2.4% and 2.3% for the experienced surgeon versus 6.1% and 0% for the less experienced surgeon, respectively, with a higher rate for the left side (P = 0.0299).

Conclusions: The left-side microvascular revision rate was higher for the less experienced surgeon. Considering that left IMVs are smaller, less experienced surgeons should carefully perform left-side free flap breast reconstructions and be prepared to convert to thoracodorsal recipient vessel use.