Purpose:
Free deep inferior epigastric artery perforator (DIEP) flap has long been considered the standard of care in autologous breast reconstruction. Asian patients often presented with smaller body mass index, and their abdominal tissue tends to be relatively insufficient. A smaller flap can be harvested comparing to western patients. Unlike in western patients in whom simultaneous bilateral breast reconstruction using bilateral DIEP flaps are not uncommon, most of the Asian patients receive unilateral breast reconstruction with free DIEP flaps and we usually have to include a higher percentage of the flap to facilitate symmetric reconstruction. Supercharge of second vein or even inclusion of bilateral pedicle is commonly required. Shifting of mastectomy technique highlighting smaller incision over lateral chest wall via endoscopic or robotic surgery, which leads to alternation of recipient vessel used in reconstruction. Comparing to traditionally used internal mammary artery, the flow from lateral thoracic artery or thoracodorsal artery was smaller and presented as an issue in microsurgical breast reconstruction since even more robust blood supply is required for creating a soft breast without fat necrosis. This study aimed to demonstrate our experience in shifting strategy of DIEP use in Asian women following the evolution of
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mastectomy technique.
Materials and Methods:
278 patients undergoing breast reconstruction surgery with DIEP flaps by a single plastic surgeon in one medical center during October, 2008 and March, 2022 were collected. Patients were further categorized into 2 groups by the operation date, November of 2018, when the first minimal invasive mastectomy was performed. Demographic data, flap profile, vessel anastomosis and post operative complication were retrospectively reviewed.

Results:
Significantly more bipedicle vessel (15.9% vs. 7%, p<0.001) and less superior inferior epigastric vein (SIEV) (5.1% vs. 17.1%, p=0.01) were used for supercharge of the flaps after minimal invasive mastectomy was introduced. Increased flap used percentage was observed in patients with 2 vein anastomosis (72.4% vs. 80.7%, p<0.001) and bipedicle vessel used (72.4% vs. 85.3%, p<0.001). Among flaps supercharged with a second vein, SIEV was more common as the choice (96.0%, p<0.001) before minimally invasive mastectomy launched while contralateral pedicle was more common (75.9%, p<0.001) afterwards. Also, thoracodorsal vessel and long thoracic vessel were increasingly used following minimal invasive mastectomy.

Conclusion:
The strategic approach in transferring free DIEP flap for breast reconstruction can be seen along the trend of mastectomy to safely delivery the procedure of microsurgical breast reconstruction using free DIEP flaps.

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