title: Decision Making in Double-Pedicled DIEP and SIEA Abdominal Free Flap Breast Reconstructions: An Algorithmic Approach and Comprehensive Classification.
abstract: BACKGROUND
  The deep inferior epigastric artery perforator free flap is the gold standard for autologous breast reconstruction. However, using a single vascular pedicle may not yield sufficient tissue in patients with midline scars or insufficient lower abdominal pannus. Double-pedicled free flaps overcome this problem using different vascular arrangements to harvest the entire lower abdominal flap. The literature is, however, sparse regarding technique selection. We therefore reviewed our experience in order to formulate an algorithm and comprehensive classification for this purpose.
  
  
  METHODS
  All patients undergoing unilateral double-pedicled abdominal perforator free flap breast reconstruction (AFFBR) by a single surgeon (CMM) over 40 months were reviewed from a prospectively collected database.
  
  
  RESULTS
  Of the 112 consecutive breast free flaps performed, 25 (22%) utilised two vascular pedicles. The mean patient age was 45 years (range = 27-54). All flaps, but one (which used the thoracodorsal system), were anastomosed to the internal mammary vessels using the rib-preservation technique. The surgical duration was 656 min (range = 468-690 min). The median flap weight was 618 g (range = 432-1275 g) and the mastectomy weight was 445 g (range = 220-896 g). All flaps were successful and only three patients requested minor liposuction to reduce and reshape their reconstructed breasts.
  
  
  CONCLUSIONS
  Bipedicled free abdominal perforator flaps, employed in a fifth of all our AFFBRs, are a reliable and safe option for unilateral breast reconstruction. They, however, necessitate clear indications to justify the additional technical complexity and surgical duration. Our algorithm and comprehensive classification facilitate technique selection for the anastomotic permutations and successful execution of these operations.
  
  
  METHODS
  Therapeutic level IV.
authors.affiliation: Postgraduate Medical Institute, Faculty of Health Sciences, Anglia Ruskin University , Cambridge and Chelmsford , UK ; Cambridge Breast Unit, Plastic and Reconstructive Surgery Department, Cambridge University Hospitals NHS Foundation Trust , Cambridge , UK.
authors.forename: Charles M
authors.initials: CM
authors.lastname: Malata
authors.affiliation: Cambridge Breast Unit, Plastic and Reconstructive Surgery Department, Cambridge University Hospitals NHS Foundation Trust , Cambridge , UK ; Cambridge Breast Unit, Plastic and Reconstructive Surgery Department, Cambridge University Hospitals NHS Foundation Trust , Cambridge , UK.
authors.forename: Nicholas G
authors.initials: NG
authors.lastname: Rabey
keywords: Bipedicled free flaps; DIEP and SIEA breast free flaps; abdominal free flaps; breast reconstruction; double-pedicle free flaps; intra-flap and extra-flap microvascular anastomoses; rib sparing internal mammary vessel exposure; stacked free flaps