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Surgical Outcomes Of Autologous Breast Reconstruction In Low BMI Patients; Beyond The Gold Standard Diep Flap
Valeria Mejia Martinez, BS1, Y. Edward Wen, BA1, Kevin Perez, M.Sc1, Cyrus Steppe, BA1, Sami Khan, MD2, Nicholas Haddock, MD1, Sumeet Teotia, MD1.
1UT Southwestern, Dallas, TX, USA, 2Stony Brook University Medical Center, Long Island, NY, USA.

Purpose Autologous breast reconstruction provides higher satisfaction than implant-based reconstruction in women with low Body Mass Index (BMI). However, the gold standard of microvascular breast reconstruction, Deep Inferior Epigastric Perforator (DIEP) flaps, can be challenging to achieve due to the paucity of adnominal bulk in these patients. In such cases, consideration of all microsurgical reconstructive methods is necessary. This study compares operative outcomes in women with BMIs less than 23.5 following microsurgical breast reconstruction after one of three free flap methods: The deep inferior epigastric perforator (DIEP) flap, alternative flaps (I.e., lumbar artery perforator flap (LAP) or profounda artery perforator flap (PAP)), and stacked flaps.
Methods A retrospective study was conducted on thin patients (BMI < 23.5) who underwent autologous breast reconstruction between 2010 and 2021 by two senior authors (NTH, SST) at a single institution with standardized surgical protocols. One hundred and fifteen patients were analyzed and divided into three reconstructive groups: thirty-six patients underwent reconstruction with DIEP flaps, thirty-five with alternative flaps (PAP and LAP), and forty-four patients with stacked flaps. Complication rates, secondary revision rates, and fat grafting in each group were compared to the gold standard DIEP flap and analyzed using logistic regressions.  
Results The flap success rate in the DIEP group was 100%. The alternative flap group had two partial flap failures, but none were total flap loss. The stacked flap group had only one total and one partial flap loss (success rate 97.7%). The overall complication rate was 19% in the DIEP group, 43% in the alternative flaps, and 13.6% for stacked flaps. The reconstruction flap method did have a significant difference in complication risk between the three groups (p-value 0.011). Compared to the DIEP flap group, alternative flaps (PAP or LAP) had a 3.107 higher risk of overall complication (p= 0.037). Stacked flaps, however, had a comparable risk for any complication to the DIEP flaps. There was no statistical difference in the number of secondary revisions needed or the total fat grafted between the three methods.
Conclusions Autologous breast reconstruction in low BMI patients yields successful and durable results in DIEP flap. This study shows that predictable results in the thin patient population can be obtained via alternate autologous methods beyond the gold standard DIEP flap.


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