4: Four-flap Breast Reconstruction: Assessing Breast-q And Donor Site Morbidity In Bilateral Stacked Autologous Breast Reconstruction
Authors: Dickey Ryan M. , Garza Ricardo , Liu Yulun , Cho Min Jeong , Teotia Sumeet S. , Haddock Nicholas T. 
Published: July 2021

Purpose: Patients undergoing bilateral autologous breast reconstruction may benefit from increased flap volume using bilateral stacked deep inferior epigastric perforator (DIEP) and profunda artery perforator (PAP) flaps. Four-flap reconstruction patients are a unique population in which to compare donor site morbidity of the two most commonly used free flaps in breast reconstruction (DIEP and PAP). Our aim was to characterize the donor site morbidity and overall patient outcomes of four-flap breast reconstruction patients.

Methods: Retrospective chart review was performed for all patients undergoing four-flap breast reconstruction by two surgeons between 2014-2019 at a single academic medical center. Inpatient surgical site pain location and pain scores by Numeric Pain Rating Scale (NPRS) were recorded during the immediate post-operative admission. All patients were contacted to complete the BREAST-Q reconstructive module and the Lower Extremity Functional Scale (LEFS). Four-flap BREAST-Q scores were compared to bilateral DIEP and to bilateral PAP patients as reference populations.

Results: A total of 63 patients undergoing four-flap breast reconstruction were identified. BREAST-Q (n=38) scores demonstrated mean Satisfaction With Breasts of 66.1+/-32.2, Psychosocial Well-Being 70.8+/-34.3, Sexual Well-Being 44.5+/-36.5, Physical Well-Being Chest 72.8+/-32.5, and Physical Well-Being Abdomen 63.6+/-34.9. In comparison to bilateral DIEP (n=180), and bilateral PAP reconstruction patients (n=43), four-flap BREAST-Q scores were similar. No difference in BREAST-Q scores remained after matching four-flap patients to bilateral DIEP patients by Age, Race, BMI, Zip Code, and radiation history. With regard to donor site morbidity, mean instances of donor site pain location recorded at the abdomen (9.72, 95%CI[7.78-11.66]) were significantly higher than the thigh (2.82, 95%CI[1.63-4.00]) during the post-operative admission (p=<0.0001). Mean pain scores by NPRS were similar between abdomen, thigh, and breast surgical sites. Subjective survey data revealed more donor site pain at the PAP site, a patient preference for the DIEP donor site, and easier post-operative care for the DIEP donor site. Further, a majority of patients felt the thighs were aesthetically improved post-operatively (54.29%). Long term survey outcomes from the LEFS (n=35) demonstrated a mean score of 92.4% (SD 10.9). The majority of women would make the same decision for four flap breast reconstruction (81.82%).

Conclusion: This is the largest consecutive series of four-flap breast reconstruction outcomes reported to date. Patients undergoing four-flap breast reconstruction have more immediate donor site pain at the abdomen than the thigh, but more thigh pain after discharge home once ambulating. BREAST-Q scores in four-flap patients demonstrate overall high patient satisfaction that is similar to both bilateral DIEP and bilateral PAP reconstruction patients. In patients who require increased flap volume for body appropriate breast reconstruction, four-flap reconstruction is comparable to bilateral DIEP and bilateral PAP by BREAST-Q scores.