A Comparison of Complications in Completely Buried and Non-Buried Deep Inferior Epigastric Perforator Flap Breast Reconstructions

BACKGROUND: Traditionally, autologous breast reconstruction with perforator free flaps utilizes a skin paddle to allow for clinical monitoring of the flap once transferred to the breast. With the advent of alternative flap monitoring techniques, such as implantable dopplers, one may also completely deepithelialize and bury the flap in the native breast envelope, with no external component for monitoring. As buried flaps are not amenable to conventional monitoring, there is concern of flap failure going unnoticed for an extended period, drastically decreasing the chances of flap salvage. METHODS: A retrospective chart review was performed for all deep inferior epigastric perforator flap breast reconstructions done by the three senior authors from November 2017 to December 2021. Postoperative complications were compared between the buried and nonburied flap cohorts with total flap loss being the primary outcome. A propensity score matched model was created to help control confounding factors. RESULTS: A total of 404 DIEP flaps were included, with 299 in the non-buried group and 105 in the buried group. There was no statistically significant difference in total flap loss between the two groups (2.7% non-buried vs. 1.0% buried; p = 0.457). The non-buried group had a significantly higher 30-day readmission rate (9.0% vs. 1.0%; p = 0.003). Among patients undergoing nipple-sparing mastectomy, flap loss was significantly higher in the non-buried group (7.1% vs. 0%; p = 0.033), and breast dehiscence was more common in the buried group (5.8% vs. 0%; p = 0.038). However, these differences were no longer statistically significant after propensity score matching. In the matched cohort (n = 94), complication rates, including flap loss, takeback, infection, and readmission, were similar between buried and non-buried flaps. CONCLUSION: Completely buried flaps for autologous breast reconstruction demonstrated similar complication rates to flaps with a skin paddle, which opens the possibility of single-stage breast reconstructions.