Optimizing the choice between single- and bipedicled DIEP flaps: A strategy guided by 3D volumetrics and indocyanine green angiography.

[BACKGROUND] Determining the need for a bipedicled deep inferior epigastric perforator (DIEP) flap is a critical challenge in delayed breast reconstruction. The traditional, experience-based approach is often subjective and inaccurate. We aimed to evaluate a novel quantitative strategy to optimize this decision-making process.

[METHODS] Patients undergoing delayed DIEP flap reconstruction managed with a new strategy were prospectively enrolled from January 2022 to December 2024, a historical conventional cohort served as the control. The quantitative strategy combines preoperative three-dimensional measurement to define the breast volume deficit with intraoperative indocyanine green angiography to assess real-time flap perfusion. Primary endpoints were the final volume restoration ratio (VRR), rate of bipedicled flap use, and flap-related complications. Follow-up was a minimum of six months. Multivariable logistic regression was performed to control for confounders and identify independent predictors of optimal volumetric symmetry (VRR 90-110%).

[RESULTS] A total of 183 patients were included (Strategy: n = 82; Conventional: n = 101). The Strategy group demonstrated a significantly higher rate of bipedicled flaps (58.5% vs. 40.6%, p = 0.016) and optimal symmetry (45.1% vs. 25.7%, p = 0.010). Multivariable analysis confirmed the quantitative strategy as a significant independent predictor for achieving optimal symmetry (odds ratio 2.53; p = 0.005), after adjusting for demographics and defect size. The incidence of flap-related complications was significantly lower in the Strategy group (2.4% vs. 10.9%, p = 0.040).

[CONCLUSION] This strategy provides objective guidance for selecting single-pedicle versus bipedicled DIEP flaps in delayed breast reconstruction and is associated with significantly improved postoperative symmetry while reducing flap-related complications.