Background: This study aimed to provide a comprehensive analysis of factors that might contribute to abdominal donor-site morbidity after abdominally based free flap breast reconstruction. Methods: The authors performed a retrospective analysis of all abdominally based free flap breast reconstructions performed from January of 2000 through December of 2010 at their institution. Results: Overall, 89 of 1507 patients developed an abdominal bulge/hernia (unilateral: 57 of 1044; bilateral: 32 of 463). A unilateral transverse rectus abdominis musculocutaneous (TRAM) flap was significantly more likely to develop an abdominal bulge/hernia than was a muscle-sparing TRAM flap or a deep inferior epigastric perforator (DIEP) flap (9.9 percent versus 3.7 percent versus 5.9 percent; p = 0.004). However, there was no difference in the risk of developing an abdominal bulge/hernia between a muscle-sparing TRAM and a DIEP flap (p = 0.36). Patients who underwent bilateral reconstructions were 1.35 times more likely to develop an abdominal bulge/hernia than patients who underwent unilateral reconstruction, but the difference was not significant. Harvesting more fascia as occurs when both medial and lateral rows are used was significantly associated with need for mesh (p < 0.0001). Overall, placement of mesh for fascia closure reduced the odds of occurrence of bulge/hernia by 70 percent compared with primary fascia closure. Conclusions: There was no significant difference in the risk of developing abdominal bulge/hernia between bilateral versus unilateral breast reconstruction. For abdominally based free flap breast reconstruction, the extent of the fascia harvested, how it is repaired, and the amount of muscle preserved might play an important role in donor-site morbidity. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Loss of a breast free flap is a relatively rare but catastrophic occurrence. Our study aims to identify risk factors for flap loss and to assess whether different salvage techniques affect flap salvage. We performed a retrospective review of all breast free flaps performed at a single institution from 2000 to 2010. Overall, 2138 flaps were performed in 1608 patients (unilateral, 1120 and bilateral, 488) with 44 flap losses (2.1%). Age, body mass index, smoking, radiation, chemotherapy, and surgeon experience did not affect flap loss. Abdominal flaps based on a single perforator were at significantly higher risk for flap loss compared with flaps based on multiple perforators (P = 0.0007). Subgroup analysis of the subset of 166 compromised free flaps (flaps requiring a return to the operating room, an intraoperative anastomotic revision, or loss/partial loss of a free flap) demonstrated deep inferior epigastric perforator, and other flaps (superficial inferior epigastric artery and superior gluteal artery perforator) were significantly associated with flap loss [odds ratio (OR) 5.20; P = 0.03 and OR 6.91; P = 0.0004, respectively] compared with transverse rectus abdominis myocutaneous and muscle-sparing transverse rectus abdominis myocutaneous flaps. Although an intraoperative complication was not associated with a flap loss, the need for a reoperation was strongly predictive (P < 0.0001). Flap salvage was the highest within the first 24 hours (83.7%) and significantly less between days 1 and 3 (38.6%; P < 0.0001) and beyond 4 days (29.4%; P < 0.0001). Longer ischemia time was significantly associated with flap loss (P = 0.04). Salvage techniques (aspirin, heparinzation, thrombectomy, and thrombolytic) had no impact on flap salvage rates. Heparinization and thrombolytics were associated with higher loss rates (OR 3.40; P = 0.003 and OR 10.36; P < 0.0001, respectively). Free flap loss following breast reconstruction is multifactorial with higher losses in superficial inferior epigastric artery and gluteal flaps, single-perforator abdominal flaps, and longer ischemia times. Salvage rates are most successful within the first 24 hours, and the use of heparinization, aspirin, and thrombolytics does not improve salvage rates.