Going up DIEAP creek—Coventry and Warwickshire Plastic Surgery Department’s experience with lifeboats and paddles

The deep inferior epigastric artery perforator (DIEAP) flap is arguably the gold standard for autologous breast reconstruction. Despite its manifold advantages, potential flap failure, often secondary to venous congestion, is a devastating possible complication. An appropriate salvage procedure may avoid DIEAP flap loss. To identify, describe and analyse DIEAP flap salvage procedures carried out by the senior author (and Coventry and Warwickshire Hospital Plastic Surgery Clinical lead) who has a special interest in breast reconstruction, over an 8-year period. A retrospective analysis of notes and logbooks was carried out to identify DIEAP flap breast reconstructions that required salvage procedures involving anastomoses in addition to or other than the routine deep inferior epigastric artery (DIEA) and vein (DIEV) to internal mammary artery and vein (IMV). One hundred twenty-seven DIEAP reconstructed cases were identified of which seven required lifeboat procedures: (1) piggy back chimeric DIEAP/TRAM flap, (2) double barrelling and trouser legging IMV and DIEVs, (3) contralateral perforator anastomosis to stump of main ipsilateral DIEA, (4) venous graft and anastomosis to cephalic vein, (5) venous anastomosis to thoracodorsal vein and (6) multiple rib resection for friable radiotherapy damaged vessels. The DIEAP flap is an increasingly popular method of providing autologous breast reconstruction with good volume and reliable perforators. However, surgeons may find that the recipient vessels of choice or the perforators alone are not adequate to maintain a healthy, viable flap. We hope that knowledge of this department’s salvage options may add to methods described in the literature and therefore the armamentarium of others when faced with similar problems.