A case report of the scarred abdomen and DIEP surgery— contraindication or opportunity for combined abdominal wall reconstruction?

Abstract

: Various patterns of abdominal scarring are considered relative or absolute contraindications for deep inferior epigastric perforator (DIEP) flap harvest. There are implications for the vascular supply to and within the flap and also to the abdominoplasty flap used for donor site closure. In recent years, several authors have advocated techniques of safe flap harvest and donor site closure in the scarred abdomen. We present the first reported case of successful delayed DIEP breast reconstruction in a patient who was 1 year post adjuvant chemo and radiotherapy with a previous ileostomy (right abdominal wall), midline laparotomy and active colostomy (left abdominal wall). Pre-operative workup included joint plastic and colorectal consultations, routine bloods and computed tomography angiography (CTA). A joint procedure was carried out during which the active colostomy was isolated on the abdominal wall musculature and a hemi-DIEP was raised from the contralateral side with good intraflap flow despite a previous ileostomy on the flap side. The colostomy was resited in the abdominoplasty flap and the delayed breast reconstruction was successful performed. The flap, donor site and new colostomy site healed well with an uneventful postoperative course and a high level of patient satisfaction and a subjective improvement in abdominal contour for the patient. As the field of abdominal wall reconstruction grows and reliability of microsurgical breast reconstruction improves, increasingly challenging abdomens can be considered as safe donor sites for autologous breast reconstruction. Careful imaging, counselling and collaboration between plastic surgeons and colorectal surgeons can aid in appropriate management of these complex patients.