Evidence-based Algorithms for Free Deep Inferior Epigastric Perforator Flap Salvage in Autologous Breast Reconstruction

Background: Breast reconstruction with the deep inferior epigastric perforator (DIEP) free flap has become the gold standard for autologous breast reconstruction. Flap take-back to the operating room (OR) is an uncommon but difficult situation, requiring prompt and accessible resources. We conducted a literature review and independent expert review to inform evidence-based perioperative algorithms in the event of DIEP flap compromise. Methods: A review of the literature was conducted, including MEDLINE, Embase, Google Scholar, and Cochrane Controlled Register of Trials. Publications examining free flap re-exploration in breast reconstruction were used to inform evidence-based clinical algorithms. The algorithms then underwent expert review and revisions from 6 international experts in microsurgery. Results: Three evidence-based management algorithms were created. The first algorithm outlines perioperative management strategies to optimize patient care and prompt return to the OR. Nonconstricting flap inset after take-back, salvage medical strategies and postoperative management following flap failure were additionally included. Algorithms 2 (venous congestion) and 3 (vascular thrombosis) provide specific intraoperative strategies surrounding mechanical decompression, pedicle exposure, assessment and extraction of thrombosis, identification and use of alternative recipient vessels, and the usage of intraoperative thrombolytics. Conclusions: A coherent and stepwise approach to DIEP flap compromise in breast reconstruction was developed. These expert-reviewed algorithms provide an approachable and evidence-based structure to support return to the OR and serve as readily available resources.