Bipedicled DIEP Flap to Reduce Complications in Patients Treated with Radiotherapy: A Single-Center Case Series

Background: Autologous breast reconstruction after chest-wall radiotherapy (RT) remains challenging because radiation-induced vascular injury may impair flap perfusion and wound healing. Bipedicled deep inferior epigastric perforator (DIEP) flaps anastomosed to two separate recipient systems may provide greater vascular redundancy in this setting. Methods: This retrospective single-center case series, reported according to the PROCESS 2025 guideline, included 26 consecutive women who underwent unilateral bipedicled DIEP flap breast reconstruction in the setting of chest-wall RT between September 2024 and March 2026, with a minimum follow-up of 6 months. Outcomes were total flap loss, flap-related complications, donor-site morbidity, and BREAST-Q scores. Results: One pedicle was anastomosed to the internal mammary vessels and the other to an axillary branch, most often the circumflex scapular artery (18/26; 69.2%). Mean operative time was 7 h 9 min ± 47 min. No total flap loss occurred. One arterial complication (3.8%) involved the internal mammary pedicle, and the flap survived. Abdominal bulge occurred in 5 patients (19.2%). Mean BREAST-Q scores were ≥90 in all domains. Conclusions: In this case series, bipedicled DIEP flap reconstruction was associated with no total flap loss after chest-wall RT, without an apparent increase in early donor-site morbidity. The biological condition of the recipient bed may deserve consideration when selecting flap configuration; larger prospective studies are required to confirm these findings.