Donor-Site Morbidity After DIEAP Flap Breast Reconstruction

A 2-Year Postoperative Computed Tomography Comparison

Christoffer Aam Ingvaldsen, MD; Gerhard Bosse, MD; Georg Karl Mynarek, MD; Thomas Berg, MD, PhD; Tyge Tind Tindholdt, MD, PhD; Kim Alexander Tønseth, MD, PhD


Plast Reconstr Surg Glob Open. 2017;5(7):e1405 

In This Article

Abstract and Introduction


Background: The study was undertaken to provide a more complete picture of donor-site morbidity following the deep inferior epigastric artery perforator (DIEAP) flap harvest in breast reconstruction. Most studies evaluating this subject have been performed using ultrasonography. Computed tomography (CT) might provide valuable information.

Methods: In 14 patients who were reconstructed with a DIEAP flap, donor-site morbidity was assessed by comparing routine preoperative CT abdomen with CT abdomen performed 2 years postoperatively. The anteroposterior diameter and transverse diameter (TD) of the rectus muscle were measured bilaterally within 4 standardized zones. Diastasis recti abdominis (DRA) was measured in the same zones. The abdominal wall was assessed for hernias, bulging, and seromas.

Results: The operated rectus muscle had a significantly increased anteroposterior diameter in 2 zones and decreased TD in 1 zone compared with preoperative measurements. Comparing the operated and nonoperated rectus muscles, the former had a significantly decreased TD in 1 zone. Supraumbilical DRA was significantly decreased with surgery, whereas infraumbilical DRA was significantly increased. No new hernias or bulging were found. Two patients had seroma formation in the abdominal wall.

Conclusions: Symmetry of the 2 hemiabdomens is well preserved after DIEAP flap harvest; however, significant changes to the rectus muscles and DRA were observed. Hernia formation does not seem to be a postoperative complication of importance. The study indicates that DIEAP flaps result in limited donor-site morbidity, which for most patients does not outweigh the benefits of free perforator flap breast reconstruction.


The deep inferior epigastric artery perforator (DIEAP) flap is currently the first choice for both unilateral and bilateral autogenous breast reconstruction.[1] Its benefit of minimizing donor-site morbidity is ever more relevant as increasingly emphasis is put on reducing the functional and aesthetic defects at the donor-site.[2–6] Moreover, the growing trend toward bilateral breast reconstruction has made it necessary to preserve the integrity of the abdominal wall.[7] Most of the strength and stability of the abdominal wall is derived from the paired rectus abdominis muscles and the anterior and posterior rectus sheaths. The harvest of an abdominal flap implicitly violates the integrity of these structures, which may result in asymmetry, bulging, and hernia formation.[5] Several studies have shown, however, that the DIEAP flap reduces the donor-site morbidity compared with other free flaps harvested from the abdomen.[3,4,6,8] Man et al.[4] reported half the risk of abdominal bulging and hernias comparing DIEAP flaps to free transverse rectus abdominis myocutaneous flaps. Furthermore, 2 meta-analyses evaluating abdominal bulging and hernia formation demonstrated that these complications are reduced in DIEAP flap reconstructions compared with transverse rectus abdominis myocutaneous flap.[3,4]

With regard to the postoperative changes to the paired rectus bellies, the literature is more conflicting. Some studies have reported that the morphological and functional changes to the rectus muscles are minimal,[9,10] whereas others have reported significant differences concerning contractility[6,8,11] and structure.[12]

The aim of this study was to further assess the donor-site morbidity following the DIEAP flap breast reconstruction. We wanted to evaluate the long-term effects of the flap harvest on the abdominal wall with a focus on the rectus muscles, hernia, and diastasis recti abdominis (DRA). No previous studies have assessed if there are dimensional changes of the DRA—also called abdominal separation. We chose to use computed tomography (CT) in assessing the abdominal wall. This modality enables the scrupulous evaluation of structural components (directly or indirectly) affected. As most previous anatomical studies have been performed by the use of ultrasonography,[6,10,12] we believe that the use of CT provides complementary information to the discussion.