Autologous dermal flaps for implant-based reconstruction: a systematic review of modern techniques and contemporary modifications

Abstract Background Autologous dermis (autoderm) is gaining popularity as a cost-effective, well-vascularized alternative to acellular dermal matrix (ADM) and synthetic meshes in implant-based breast reconstruction (IBBR). The inferior dermal flap (IDF), originally developed for ptotic breasts, has been modified to address thin mastectomy flaps and improve implant coverage. This systematic review synthesizes recent literature on contemporary IDF use and modifications. Methods We conducted a systematic review following PRISMA guidelines. Comprehensive searches were performed across Embase, Ovid Medline, Scopus, Cochrane CENTRAL, CDSR, and Clinicaltrials.gov from January 1, 2020, to July 22, 2025. Inclusion criteria encompassed case reports, case series, cohort studies, and RCTs focused on dermal autografts for IBBR. Studies focused solely on subpectoral implant coverage, nipple-areolar complex reconstruction, or autologous flap-based procedures were excluded. Quality assessment utilized MINORS criteria and JBI Critical Appraisal Checklist. Results Of 15,678 articles screened, 28 studies met inclusion criteria. Techniques identified included classic IDF, hybrid IDF-ADM/mesh combinations, vertical mastectomy patterns, skin flap bridging, hammock variants, and adaptations for non-ptotic breasts. Major complication rates ranged from 0 to 21% across various modifications, with highest rates in radiated cohorts. Reported series suggest that IDF techniques can provide vascularized coverage and implant support comparable to synthetic alternatives, though direct comparative evidence remains limited. A practical framework is also proposed to guide incision design selection based on the dominant pattern of skin redundancy. Conclusions IDF techniques offer versatile, patient-specific reconstructive options addressing diverse clinical challenges while reducing dependence on synthetic materials. These autologous dermal flap variations are associated with favorable outcomes and potential cost-effectiveness, though prospective research is needed to standardize outcomes and confirm long-term benefits. Level of Evidence Not gradable.