The application of double pedicled free deep inferior epigastric artery perforator flap breast reconstruction following mastectomy in unilateral breast cancer

Introduction

Breast cancer has become a major malignancy among women, and there is a disturbing trend of earlier onset. This situation not only brings significant physical challenges but also has a profound psychological impacts, especially for young women undergoing mastectomy. The Advancements in autologous flap breast reconstruction techniques have offered feasible solutions to these challenges (1). As the field of oncoplastic breast surgery keeps evolving, surgeons must balance the two goals of oncological safety and aesthetic outcomes, striving to minimize surgical complications while achieving the best reconstructive results that meet the expectations of patients (2).

The deep inferior epigastric perforator (DIEP) flap has been well-established as the gold standard for autologous breast reconstruction, as it is recognized for its ability to provide sufficient tissue volume and reliable vascular supply while maintaining the integrity of abdominal muscles (1). Despite its many advantages, the procedure is highly technically-demanding, characterized by a steep learning curve and significant intraoperative challenges. Hence, the modification of breast reconstruction surgical methods is of great significance for improving the success rate and postoperative recovery of breast reconstruction.

Double pedicled DIEP employs double vascular pedicles, offering a better blood supply to the reconstructed breast and reducing the risk of complications like flap necrosis. In contrast to unilateral pedicled DIEP, double-pedicled DIEP can guarantee a strong perfusion of the entire flap and prevent distal fat necrosis and related discomforts. The utilization of double pedicled DIEP flaps, although less frequently reported compared to unilateral flaps, provides substantial benefits to patients who require larger tissue volumes, such as those with macromastia or significant breast ptosis. However, there are few reports and lack of mature experience. Therefore, it is necessary to conduct relevant research to accumulate experience for the improvement of breast reconstruction technology.

This study performs a retrospective analysis to compare double pedicled DIEP flap breast reconstruction with unilateral pedicled DIEP, focusing on preoperative planning, surgical skills, postoperative management, and breast appearance. When dealing with large and drooping breasts clinically, double pedicled DIEP flaps, as opposed to unilateral pedicled DIEP flaps, usually do not need to remove tissues from regions III and IV. Due to the abundant blood supply, the reconstructed breast will be softer and have a better feel. Simultaneously, the target blood vessels are well-defined, and the rectus abdominis muscle and anterior sheath are not damaged, thereby preserving the abdominal wall function after surgery. This article aims to enhance this reconstruction method, shorten the recovery time, and improve the clinical management of patients undergoing breast cancer autologous reconstruction. We present this article in accordance with the SUPER reporting checklist (available at https://gs.amegroups.com/article/view/10.21037/gs-2026-0149/rc).

Preoperative preparations and requirements

General information

All procedures performed in this study were in accordance with the Declaration of Helsinki and its subsequent amendments. This study was approved by the Ethics Committee of National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital & Shenzhen Hospital (IRB number: XJS2024-22). Written informed consent was obtained from the patients for publication of this article and accompanying images. A copy of the written consent is available for review by the editorial office of this journal. This retrospective analysis included patients who were diagnosed with breast cancer and underwent free DIEP flap breast reconstruction at the Breast Surgery Department of National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital & Shenzhen Hospital from January 2022 to December 2023. This is a tertiary grade A specialized hospital for oncology. All the surgeries in this study were conducted in the operating room. The surgical team consists of surgeons, anesthesiologists and nurses, who work together to complete the operation. Over the past five years, the surgeons have completed training courses in microsurgical suturing techniques and breast aesthetics. They have performed over 150 such surgeries cumulatively and form an experienced surgical team. The inclusion criteria for this study were as follows: (I) female patients diagnosed with breast cancer, aged between 18 and 65 years old; (II) patients requiring unilateral mastectomy and having the intention to undergo DIEP flap reconstruction (3,4); (III) no tumor recurrence or distant metastasis as confirmed by preoperative imaging; (IV) a body mass index (BMI) ranging from 18 to 35 kg/m²; and (V) patients who were compliant with regular follow-up and monitoring. All breast cancer patients in this study were weighed after the removal of the breast gland. We defined a breast gland weight of ≥600 g as a large breast. For large breasts, we tended to choose the double pedicle DEIP flap.

According to the following flow chart, our center has special criteria for the selection of unilateral-pedicle DIEP and double pedicle DIEP. (I) Unilateral-pedicle DIEP: the breast is of small to medium volume, has no or mild droop, does not require postoperative radiotherapy, and the preoperative CTA examination shows a dominant perforating branch on one side of the abdominal wall. (II) Double pedicle DIEP: the breast is large with moderate to severe ptosis, requires postoperative radiotherapy, and preoperative CTA examination reveals double dominant perforating branches of the abdominal wall (Figure 1).

Figure 1 The flow chart and the entire operation process of DIEP. 1) The inferior epigastric artery is formed within the rectus abdominis muscle and converges with the superior epigastric artery at the navel to form a vascular communication network; 2) the shape of the perforating branches of the inferior abdominal artery in the bilateral rectus abdominal muscle of the abdominal wall and the shape of the perforating branches entering the flap tissue; 3) after double inferior abdominal artery perforator flap free; 4) the double sets of vascular pedicles in the donor area of free flap are anastomosed with the proximal and distal ends of the internal vessels in the chest respectively. 5) reconstruction breast shaping is performed according to the healthy side breast, and the abdominal wall incision was sutured.

Preoperative vascular evaluation

Computed tomography angiography (CTA), with the use of contrast agents, was utilized to accurately define the origin, diameter, and dominance of perforator vessels, making it the preferred approach for preoperative assessment of abdominal perforator vessels (5). All the patients underwent CTA examinations preoperatively to provide vascular information for surgeons.

Step-by-step description

Breast cancer surgical treatment

Patients underwent unilateral breast-mastectomy surgery, either a nipple-areola complex sparing mastectomy (NSM) or a skin-sparing mastectomy (SSM). The retained skin thickness was approximately 0.3 to 0.5 cm to ensure the complete removal of the glandular tissue. Frozen-section pathology was performed on the tissue beneath the nipple-areola complex to assess for tumor invasion, thereby determining whether the nipple-areola complex could be preserved. Additionally, axillary management was carried out in all patients, either through axillary lymph node dissection or sentinel lymph node biopsy, to address the regional primary lesions.

Donor site flap dissection

Our approach included: (I) identifying all viable perforators and ultimately selecting the dominant perforator for dissection; (II) utilizing preoperative CTA to identify the location of the dominant perforator and directly dissecting the perforator with a diameter ≥1.0 mm. As depicted in Figure 2, the inferior abdominal artery was located within the rectus abdominis muscle, and its perforating branches passed through the rectus abdominis muscle and entered the subcutaneous adipose tissue. During the surgical procedure, dissection was carried out based on the anatomical diagram of the inferior abdominal artery and its perforating branches, as shown in Figure 2. After dissecting both the inferior abdominal artery and its perforating branches along with the adipose tissue of the abdominal wall, a double pedicled DIEP free flap was created. As presented in Figure 3, double pedicled DIEP flaps were dissected for all patients, with the positions of the dominant perforators being symmetrical. There was no significant damage to the rectus abdominis muscle and its sheath, and all abdominal walls could be directly sutured without the requirement for a hernia mesh.

Figure 2 (A) The schematic diagram of the main inferior abdominal artery within the rectus abdominis muscle and penetrating the rectus abdominis muscle into the subcutaneous adipose tissue. (B) The main and perforating branches of the inferior abdominal artery after the flap is free. (C,D) Preoperative CTA scans of the double deep inferior epigastric perforator vessels with dominant perforators. CTA, computed tomography angiography; DIEP, deep inferior epigastric perforator.

Figure 3 Lower abdominal flap before pedicle division, showing minimal damage to the rectus abdominis muscle and its sheath, thus not requiring the use of hernia mesh and preserving abdominal wall function. The dashed line shows the direction of the vessel pedicle.

Recipient site vessel preparation

The recipient site vessels were the internal thoracic vessels (Figure 4). The process entailed cutting a small part of the pectoralis major and intercostal muscles to expose the underlying internal thoracic vessels. Approximately 2 cm of the anterior end of the third rib cartilage was resected to fully expose the internal thoracic artery and vein. Under the microscope, the distal and proximal ends of the vessels were prepared and clamped (Figure 4). During the dissection, any identified internal mammary lymph nodes (IMLNs) were excised and sent for pathological examination.

Figure 4 Internal thoracic vessels. (A) The internal thoracic artery and vein before recipient site preparation; (B) the vessels clamped after preparation.

Vascular anastomosis

The donor site pedicles in patients consisted of 1 artery and 2 veins, while the recipient site vessels (internal thoracic vessels) consisted of 1 artery and 1 vein. The two sets of inferior epigastric pedicles were anastomosed by selecting the dominant veins with the distal and proximal ends of the internal thoracic veins. The perfusion pressure of blood flow to the distal and proximal ends of the heart within the thoracic cavity differs, and the presence of venous valves can affect the effectiveness of blood flow reconstruction at the distal and proximal ends of the heart. Similarly, the donor arteries were anastomosed with the distal and proximal ends of the internal thoracic artery. Using 4× magnification, the double inferior epigastric pedicles were meticulously anastomosed (totaling 2 arteries and 2 veins). After completing the anastomoses, the vascular clamps were released to confirm the patency and satisfactory perfusion of the flaps.

Technical point 1

Unilateral-pedicled DIEP flap is a commonly used method for breast reconstruction. When dissecting a unilateral-pedicled DIEP flap, multiple perforators need to be dissected to ensure blood supply, which will damage the rectus abdominis and affect the patient’s quality of life. However, when using double pedicled DIEP surgery, when dissecting double pedicled DIEP flaps, dissecting a single perforator or multiple perforators can ensure good blood supply to the flap and is not easy to damage the rectus abdominis, thereby protecting the related functions of the abdominal wall. At the same time, it will reduce the psychological pressure of surgeons during the perioperative period. This study compared the effects of double pedicled and unilateral pedicled flaps and proposed the advantages of double pedicled DIEP in large or ptotic breasts.

Breast shaping (innovative point 1)

The operating table was adjusted to the semi-Fowler’s position, with the patient’s arms extended to optimally expose both breasts. The abdominal incision was evaluated for tension-free closure. The flap was fixed to the chest wall using 4-0 absorbable sutures to shaped the reconstructed breast to resemble the contralateral breast. For patients needing postoperative radiation therapy, the reconstructed breast was designed to be approximately 10% larger than the contralateral breast to compensate for the possible volume reduction due to radiation effects, thereby maintaining symmetry.

Technical point 2

Adjust the operating table to a semi-sitting position and extend the patient’s arms to best expose both breasts. Evaluate whether the abdominal incision can be closed without tension. Use 4-0 absorbable sutures to fix the flap on the chest wall so that the reconstructed breast is similar in shape to the contralateral breast. For patients who need postoperative radiotherapy, the reconstructed breast is designed to be about 10% larger than the contralateral breast to compensate for the possible volume reduction due to radiotherapy effects and maintain symmetry.

Postoperative considerations and tasks

Postoperative management

Perioperative prophylaxis involved the intravenous administration of 1.5 g cefuroxime, and the operating room temperature was maintained at approximately 26 ℃. Postoperatively, flap perfusion was closely monitored according to the following protocol: (I) every 2 hours for the first 1–3 days; (II) every 4 hours from days 4–7; (III) every 12 hours after day 7. Traditional methods, such as observing the color, texture, turgor, capillary refill, and pinprick bleeding of the flap, were employed to assess perfusion, supplemented by Doppler ultrasound and indocyanine green (ICG) angiography when necessary.

Postoperative care encompassed anticoagulation, thromboprophylaxis, fluid resuscitation, anemia correction, and enhanced nursing care. The urinary catheter was removed, and patients were encouraged to ambulate in a bent-over posture on the 2–3. Compression garments were used to aid in reshaping the reconstructed breast.

Technical point 3: postoperative patient and doctor satisfaction assessment, using the scoring scale Kyungpook National University Hospital BREAST Satisfaction Survey, Harvard scale (4-point Likert scale), and satisfaction results.

Follow-up

Patients were regularly followed up after the surgery to monitor their recovery and detect any potential complications. Follow-up visits were arranged at one week, one month, three months, six months, and one year after the surgery. At each visit, a physical examination was carried out, and any concerns or issues were dealt with.

Data collection

Clearly mention the key data obtained in the research, such as sample size, specific values of measurement indicators, percentages, averages, standard deviations, etc. The Student’s t-test or Chi-squared test was used to detect the difference between continuous or categorical variables. The continuous variables were analyzed by Student’s t-test. The categorical variables were analyzed by Chi-squared test of Fisher’s exact test (when expected cell count <5), with justification for test selection. The analysis of variance (ANOVA) was used to test whether there are significant differences in the means of continuous variables between different categories. Pearson correlation coefficient and Spearman’s rank correlation coefficient are used to measure the strength of the linear relationship between two normally or non-normally continuous variables. Regression analysis is used to determine the relationship between the independent of dependent variables and the dependent variable. Adjustment for multiple testing was employed for multiple comparisons. 95% confidence intervals (95% CIs) were reported for all primary and secondary outcome estimates. Besides, the post-hoc power analysis was conducted because of the group imbalance (sample sizes: 21 vs. 71). For complication rates (7% vs. 0%), the non-significant result (P=0.34) was interpreted as insufficient statistical power rather than equivalence, consistent with the small sample size in one group. All statistical tests were two-sided, and P<0.05 showed obvious different.

Tips and pearls

Clinical information

During this period, we admitted nearly 819 breast cancer patients for surgery. Among them, about 160 (19.5%) patients received breast reconstruction surgery, and about 92 (57.5%) received DIEP breast reconstruction. The double pedicled DIEP group included 21 (22.8%) breast cancer female patients with large and drooping breasts, aged 31–50 years old, with the mean age of 38.81±0.95 years old. It included 3 cases of triple-negative breast cancer, 5 cases of human epidermal growth factor receptor 2 (HER-2) positive, 6 cases of Luminal A and 7 cases of Luminal B. Two cases were in stage I, 15 cases were in stage II, and 4 cases were in stage III. Among them, 14 cases received neoadjuvant chemotherapy, 6 cases received chemotherapy, and 15 cases received radiotherapy. All patients used free lower abdominal flaps for breast reconstruction. The breast tissues removed from all the patients in the study were all weighed, and their weights were consistent with those of the trimmed flaps. The flap size ranged from 11 cm × 22 cm × 4.0 cm to 14 cm × 30 cm × 5.5 cm, and the weight was between 440 and 900 g, with an average of 674.76±28.97 g. The operation time was 521.33±19.26 minutes. The unilateral pedicled DIEP group included 71 (77.2%) female patients, aged 31–50 years old, with an average age of 40.58±0.64 years old. It included 11 cases of triple-negative breast cancer, 19 cases of HER-2 positive, 41 cases of Luminal A and B. Six cases were in stage I, 54 cases were in stage II, and 11 cases were in stage III. Among them, 44 cases (62.0%) received neoadjuvant chemotherapy, 22 cases (30.1%) received chemotherapy, and 47 cases (66.2%) received radiotherapy therapy. The flap size ranged from 10 cm × 20 cm × 3.0 cm to 13 cm × 28 cm × 5.0 cm, and the weight was between 280 and 750 g, with an average of 521.01±13.65 g. The operation time was 447.55±9.68 minutes. No obvious difference was found in basic information between the two groups (Table 1).

The degree of breast ptosis plays an important role in the selection of single-pedicled and double-pedicled DIEP. Breast ptosis is classified according to the standard first described by Regnault in 1976 (6) (see in Table 2). In the double pedicle DIEP group, among the 21 patients, there were 7 cases (33.3%) of mild ptosis, 8 cases (38.1%) of moderate ptosis, and 6 cases (28.6%) of severe ptosis (see in Table 3 and Figure 5). In the unilateral pedicle DIEP group, 63 cases (88.7%) had no breast ptosis, and 8 cases (11.3%) had breast ptosis. Among them, there were 5 cases (7.0%) of mild ptosis, 2 cases (2.8%) of moderate ptosis, and 1 case (1.4%) of severe ptosis (see in Table 3).

Figure 5 Preoperative markings. With large and ptosis breast, both A and B have completed neoadjuvant chemotherapy, who are not candidates for breast conservation. Patient A is multiple tumor lesions, and the distance of the tumor from the nipple-areola is greater than 2 cm. While in patient B, the tumor was located below the nipple areola, and preoperative imaging indicated that the tumor had invaded the nipple. The tumor location and the area for lower abdominal flap harvesting are marked preoperatively. Panel A represents patients who underwent NSM, and panel B represents patients who underwent SSM. NSM, nipple-areola complex sparing mastectomy; SSM, skin-sparing mastectomy.

All patients underwent preoperative CTA examination, which is helpful to select appropriate patients and reduce the average operation time (7). Routine preoperative CTA was conducted for all 21 patients, allowing for the visualization of double dominant perforator vessels, as illustrated in Figure 2C,2D. This imaging modality significantly contributed to the optimization of surgical planning and reduction of intraoperative duration (7). Preoperative CTA scans of the same patient showing the double DIEP vessels with dominant perforators.

Each flap in the double pedicled flap group is a complete lower abdominal flap. The flap sizes ranged from 11 cm × 22 cm × 4.0 cm to 14 cm × 30 cm × 5.5 cm, the weight is between 440 and 900 g, with an average of 674.76±28.97 g (Figure 3). Among them, 5 cases are double-pedicle single perforator and 16 cases are double-pedicle multiple perforators. The length of the vascular pedicles is 8–14 cm, with an average length of 10 cm. As shown in Figure 3, there was no significant damage to the rectus abdominis muscle and its sheath, and all abdominal walls could be directly sutured without the need for hernia mesh.

For the DIEP surgery, it is beneficial to detect internal lymph node metastasis. In the double pedicled DIEP group, intraoperative IMLN biopsies were performed in 10 patients, among which 5 cases were confirmed to have tumor metastasis and received postoperative radiotherapy in the internal mammary area. In the unilateral pedicled DIEP group, intraoperative IMLN biopsies were performed in 12 patients, among which 3 cases were confirmed to have tumor metastasis and received postoperative radiotherapy in the internal mammary area.

In terms of postoperative complications, there were no obvious complications in the double pedicled DIEP group. As shown in Table 1, it is evident that the double pedicle DIEP group did not experience any significant complications. Conversely, within the unilateral-pedicle DIEP group, 5 cases (7.0%) had surgical complications, including 1 case of flap necrosis leading to surgical failure, 2 cases of partial necrosis of the distal flap, and 2 cases feeling discomfort due to fat nodules at the distal end of the flap. There was no difference between the two groups (P>0.05).

Patients in the double pedicled DIEP group are usually discharged within two weeks after surgery. In subsequent treatments, 15 patients received radiotherapy, among which 3 cases had mild radiodermatitis, which was relieved after symptomatic treatment. Twenty patients received postoperative adjuvant therapy, including chemotherapy and endocrine therapy. In unilateral-pedicle DIEP group (Table 1), 12 cases (16.9%) had moderate to severe radiodermatitis due to radiotherapy, while there was no such side effect was found in double pedicle DIEP group. There was a significant difference between the two groups (P<0.05). Neither group had symptoms of lymphedema of the affected limb during the follow-up period.

In unilateral-pedicle DIEP group, erythema, edema, and hyperpigmentation of the reconstructed breast skin are observed, along with potential discomfort such as increased skin temperature, pruritus, and paresthesia. Clinically, conservative management approaches including local cooling and topical medication application are commonly employed to address this issue.

In double pedicle DIEP group, all patients recovered uneventfully, without any surgery-related complications, and the flaps survived well. Patients were discharged within 7–14 days after the operation. The follow-up period ranged from 9 to 22 months, with an average of 15.24±0.95 months. During the follow-up, no cases of tumor recurrence or metastasis were observed. In the unilateral-pedicle DIEP group, patients were discharged within 7–15 days after the operation. The follow-up period ranged from 9 to 33 months, with an average of 22.91±0.74 months. There was obvious difference in the length of hospital stay between the two groups, patients stay shorter in the double pedicle DIEP group than that in the unilateral-pedicle DIEP group. And the difference in follow-up time was due to the larger number of unilateral-pedicle DIEP cases at the beginning of 2022 in our center.

During follow-up, regardless of whether it was unilateral or double pedicle DIEP breast reconstruction, none of the patients had lymphedema symptoms in the affected limb.

Aesthetic outcomes and patient satisfaction

The breast satisfaction survey of Kyungpook National University Hospital in South Korea was used to assess patient satisfaction six months after surgery. The aesthetic results were evaluated through patient self-reported satisfaction scores and blind evaluations by three surgeons (see in Tables 4,5) (8).

In the double pedicled DIEP group, 95% of patients were satisfied with the appearance of the reconstructed breast compared to the contralateral breast, and 95% of patients felt comfortable in public and believed that the decision to choose breast reconstruction was correct; 95.3% of the overall patient satisfaction was excellent or good, and 95.2% of the doctor’s evaluation was excellent or good. These are slightly higher than those in the unilateral pedicled DIEP group. In the unilateral pedicled DIEP group, 88.8% of the overall patient satisfaction was excellent or good, and 87.3% of the doctor’s evaluation was excellent or good. In the double pedicled DIEP group, 4.8% of doctors and 4.7% of patients rated it as fair, and there were no poor reviews (see in Table 6).

While in the unilateral-pedicle DIEP group, it was relatively higher. 5.6% of doctors and 4.3% of patients rated it as fair, and 5.6% of doctors and 8.4% of patients rated it as poor or very poor. Although no significant difference was statistically calculated between the two groups, in the evaluations of patients and doctors, double pedicled DIEP still has important advantages.

As shown in Figure 6, the reconstructed breasts are symmetrical, beautiful, natural, and the patient satisfaction is high. During the follow-up period, no tumor recurrence or metastasis was found.

Figure 6 Postoperative appearance of DIEP breast reconstruction at 6 months. (A) Patients post-NSM; (B) patients post-SSM. The reconstructed breasts are symmetrical, aesthetically pleasing, and natural in appearance. DIEP, deep inferior epigastric perforator; NSM, nipple-areola complex sparing mastectomy; SSM, skin-sparing mastectomy.

Discussion

Breast reconstruction technology is of great significance in modern breast cancer treatment. It is of great significance for improving patients’ confidence, satisfaction and meeting the demand for beauty. Breast cancer is currently at a high global incidence level. The progress of microsurgery, the improvement of comprehensive treatment methods, the improvement of prognosis and the younger trend of onset age have made patients and doctors have higher and higher requirements for breast cancer surgery. Breast reconstruction, especially double-pedicled breast reconstruction, plays an important role in improving the postoperative quality of life, psychological needs and happiness of breast cancer patients. The DIEP flap is an improved version of the traditional rectus abdominis myocutaneous (TRAM) flap. Holmstrom and Robbins first used the TRAM flap for breast reconstruction (9,10). Subsequently, Koshima and Soeda pioneered the DIEP flap in 1989 (11). Today, the DIEP flap has become the gold standard for breast reconstruction. It provides a large amount of tissue that matches the natural softness and elasticity of the breast, while maintaining the function of the rectus abdominis and reducing surgical complications (12,13). It is an excellent choice for autologous breast reconstruction (14,15).

The internal thoracic vessels are the preferred recipient vessels in DIEP reconstruction. The DIEP flap technique has developed from simply focusing on flap survival to striving to reduce the donor-site morbidity, lower surgical complications and achieve better aesthetic results. When choosing the recipient vessels, the internal thoracic vessels are the first choice due to their central position on the chest wall, ease of dissection and less damage from radiotherapy (16-18). The experience of our center suggests that for patients with an intercostal space width of about 1–2 finger widths, the internal thoracic vessels can be exposed by cutting the intercostal muscles without the need to resect the costal cartilages. For patients with a narrow intercostal space, it is recommended to resect the front end of the costal cartilages to increase the space for microsurgical operations and improve the accuracy of vascular anastomosis.

Double pedicled DIEP has significant advantages in breast cancer surgeries for patients with large and ptotic breasts. For most medical institutions, only unilateral pedicled DIEP is usually performed, and the blood supply of the flap cannot be guaranteed, resulting in poor softness and shape of the breast after surgery. If the double pedicled DIEP flap is used, especially for patients with larger and ptotic breasts, the double pedicled DIEP flap provides more tissue volume and better blood supply, thereby making the shape, softness and naturalness of the breast better and the patient satisfaction higher. Since the Kyungpook Survey is not internationally validated, the BREAST-Q survey would be applied as the preferred instrument for future work. The double pedicled DIEP flap uses two vascular pedicles to provide a larger tissue volume and enhanced blood supply, and is suitable for patients who need a large-scale breast reconstruction. It ensures the natural and symmetrical appearance of the reconstructed breast and can avoid additional prosthesis implantation surgeries or contralateral breast reduction surgeries.

The choice of double pedicled DIEP can provide sufficient blood supply to the flap and protect the function of the rectus abdominis muscle. The application of preoperative CTA can effectively help in the selection of the blood supply for DIEP (19). For a large-area DIEP tissue, two to three perforator vessels can be cut simultaneously, or the double inferior abdominal wall arterial perforator vessels can be used to increase the blood supply of the flap (20). However, when using unilateral pedicled DIEP, when dissecting multiple perforators to obtain a larger flap tissue and better blood flow, the rectus abdominis muscle and the anterior sheath may be damaged, leading to the risk of a weak abdominal wall or even an abdominal wall hernia after surgery. In the case of double pedicled DIEP, only dissecting a single dominant perforator is required to ensure the blood transport of the entire flap without damaging the rectus abdominis muscle and the anterior sheath, and protecting the function of the abdominal wall. Therefore, this surgery was non-invasive. In this study, the rectus abdominis muscle was not damaged during the dissection of the double DIEP flap, and there was no need to use a hernia repair mesh, thus preserving the function of the abdominal wall (21,22). In addition, double pedicled DIEP can provide a larger amount of flap tissue to meet the needs of larger tissue repair. Therefore, when transplanting double pedicled DIEP flaps, it is necessary to re-establish blood flow for the two sets of vascular pedicles respectively. Due to the double blood supply of double pedicled DIEP, the blood circulation is better. This study found that 5 cases (7.0%) in the unilateral pedicled DIEP group had surgical complications, including flap necrosis, partial necrosis of the distal flap, and discomfort caused by fat nodules at the distal end of the flap, resulting in breast deformity or poor reconstruction results. None of the patients with double pedicled DIEP had the above-mentioned conditions, and the patient satisfaction was better than that of the unilateral pedicled DIEP group.

The stable perfusion of double pedicled DIEP is beneficial to reducing side effects such as radiodermatitis caused by radiotherapy. Hamdi has suggested that for patients with large and ptotic breasts, the use of double-pedicle flaps provides better symmetry and natural droop, resulting in superior reconstruction outcomes (23). In this study, all patients required a large amount of tissue due to large and ptotic breasts, and 4 of them had vertical cesarean section scars. The use of double pedicles ensured the stable perfusion of the flap. All the DIEP breast reconstruction surgeries in this study were immediate breast reconstructions after breast cancer surgery. There was no difference in the scope, duration or dosage of postoperative radiotherapy. Radiotherapy was generally administered 4 to 8 weeks after the surgery with a total of 50 or 43.5 Gy. The assessment was conducted one month after the end of the radiation therapy. Among the 15 patients who received postoperative radiotherapy, only 3 had mild radiodermatitis, which was relieved after local treatment. No severe radiation-related complications were observed. There were 12 cases in the unilateral pedicled DIEP group that had moderate to severe side effects of radiotherapy. It can be seen that patients with double pedicled DIEP have fewer side effects of radiotherapy because of better blood supply and better radiotherapy tolerance.

The DIEP breast reconstruction surgery is conducive to the detection of IMLN metastases that are negative in clinical evaluation. IMLN metastasis is one of the important metastasis routes of breast cancer and also an important basis for determining the stage and formulating the treatment plan. The prognosis of patients with both IMLN metastasis and axillary lymph node metastasis is worse than that of those with a single metastasis (24,25). Previous studies have found that 9.2% of those with negative axillary lymph nodes have IMLN metastases, 19.6% of those with 1–3 positive axillary lymph nodes have IMLN metastases, and the proportion of IMLN-positive patients among those with 4 or more positive ALN is 38.3% (26). At present, the indications for radiotherapy in the internal mammary region in clinical practice and guidelines are mainly based on the high-risk factors of IMLN metastasis. Simply relying on the staging of axillary lymph node metastasis to select adjuvant treatment regimens is not comprehensive. Comprehensive consideration can provide a more reliable basis for the treatment of breast cancer patients (27,28). During the vascular preparation process of the single-tissue DIEP flap, it is usually possible to expose the vascular anastomosis area without cutting the costal cartilage, but compared to the double-tissue DIEP flap, the rate of IMLN biopsy is lower. During the patient follow-up process, we found that patients who had the costal cartilage cut experienced pain in the anterior chest area, while the incidence of anterior chest pain was lower in patients who did not have the costal cartilage cut. Therefore, for the single-tissue DIEP flap, we do not routinely cut the costal cartilage. Additionally, single-artery DIEP usually does not require cutting the costal cartilage and thus cannot fully expose the internal mammary region, resulting in a lower probability of discovering IMLNs. In contrast, double-artery DIEP requires cutting the anterior end of the third costal cartilage to meet the requirements for double vascular pedicle anastomosis, increasing the probability of exposing IMLNs. This was an opportunistic IMLN biopsy. The breast reconstruction surgery can detect the metastasis of IMLNs, make up for the deficiency of clinical staging in imaging, and provide a certain clinical basis for the chemotherapy and postoperative radiotherapy of breast cancer patients. It is conducive to formulating a reasonable comprehensive treatment plan and improving the treatment effect of patients.

Limitations

Compared to some large-scale studies, the sample size of this article is merely 21 patients. This might not fully represent a broader patient population, thereby influencing the universality and reliability of the research results. This is a retrospective study. In clinical practice, for patients with large breast volume or obvious ptosis, or those who are assessed to require postoperative radiotherapy before the operation, we usually choose the double-tissue DIEP flap for breast reconstruction. In our data, 15/21 patients (71.4%) in the double-tissue group received radiotherapy, which was higher than 47/71 (66.2%) in the single-tissue group. Choosing the double-tissue DIEP was predetermined before the operation, which may have selection bias.

Conclusions

Therefore, we summarize four grounds for using double vascular pedicles as follows: (I) patients with macromastia or ptosis require a large amount of tissue; (II) evaluation of IMLNs; (III) postoperative radiotherapy is required, reducing side effects such as radiodermatitis caused by radiotherapy; (IV) there are vertical cesarean section scars which need sufficient blood supply to the flap. By comparing the clinical applications of single-pedicle and double-pedicle DIEP, this research offers viable DIEP strategies and valuable practical insights and techniques for breast cancer patients who have large and ptotic breasts and are slated for subsequent radiotherapy regimens. Using double pedicled breast reconstruction can improve the blood supply of the flap, reduce postoperative complications, increase the detection opportunity of IMLN metastasis, provide more comprehensive evaluation conditions for subsequent comprehensive treatment, and can reduce the incidence of radiodermatitis and improve the satisfaction of patients and surgeons.

Acknowledgments

The abstract was presented as a poster at the 19th St. Gallen International Breast Cancer Conference, held at the Austria Center Vienna, Austria, in 2025. We thank the Department of Breast Surgery and the General Surgery Department for providing surgical data and case materials.

Footnote

Reporting Checklist: The authors have completed the SUPER reporting checklist. Available at https://gs.amegroups.com/article/view/10.21037/gs-2026-0149/rc

Peer Review File: Available at https://gs.amegroups.com/article/view/10.21037/gs-2026-0149/prf

Funding: This research was supported by Shenzhen Medical Research Fund (No. D2402001, to J.G. and No. A2503077), Chinese Academy of Medical Sciences Cancer Hospital Shenzhen Hospital Youth Start-up Fund Project (to L.X.), the National Natural Science Foundation of China (No. 82102987, to Q.C.), and Shenzhen Postdoctoral Research Funding for Postdoctoral Fellows Coming to Shenzhen (No. C030123002, to Q.C.).

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://gs.amegroups.com/article/view/10.21037/gs-2026-0149/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the Declaration of Helsinki and its subsequent amendments. This study was approved by the Ethics Committee of National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital & Shenzhen Hospital (IRB number: XJS2024-22). Written informed consent was obtained from the patients for publication of this article and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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