Outcome after urgent microvascular revision of free DIEP, SIEA and SGAP flaps for autologous breast reconstruction

Introduction: Microvascular complications after free flap breast reconstruction are devastating, and revision of a compromised breast reconstruction is very challenging. The aim of this study was to review the different characteristics of urgent microvascular revision in DIEP, SIEA and SGAP flaps and to evaluate the final outcome after revision. Materials and methods: A retrospective chart review was performed for all patients who underwent an autologous breast reconstruction with a DIEP, SIEA or SGAP flap at the University Hospitals of Leuven between August 1997 and December 2013. The number of revisions, time to revision, reason for revision, and outcome after microvascular free flap revision were analysed. Results: A total of 1562 free flaps were evaluated during the study period, of which 4.42% required urgent exploration. DIEP flaps (3.38%) had a statistically significant lower revision rate than SIEA flaps (11.76%) and SGAP flaps (8.42%). Venous insufficiency was the main reason for revision of DIEP flaps (86.7%) and SGAP flaps (62.5%). SIEA flaps mostly failed because of an arterial problem (62.5%). SIEA flaps (62.5%) had a higher revision failure rate than DIEP flaps (37.8%) and SGAP flaps (12.5%). We found a statistically significant difference (p < 0.001) in the outcome of revision in DIEP flaps in correlation to the time to revision. Our overall flap failure rate was 1.79% (DIEP 1.28%; SIEA 7.35%; SGAP 1.05%). Conclusions: The DIEP flap remains the most reliable flap for microvascular breast reconstructions. SIEA flaps are only performed when no suitable perforator for a DIEP flap is present. Multiple revisions are no longer performed, as the outcome after more than one revision is very disappointing. The difference in reason for revision between the different flaps led to the introduction of some technical refinements. (C) 2016 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.