The Efficacy of Half Purse Suture Technique in Eliminating “Dog-Ear” Deformity at Donor Site Incision in Deep Inferior Epigastric Perforator Flap (DIEP) Breast Reconstruction

Abstract

Background

To evaluate the effectiveness of the half purse suture technique in eliminating the “dog-ear” deformity at the donor site incision of the Deep Inferior Epigastric Perforator flap (DIEP) for breast reconstruction.

Method

From May to October 2022, the half purse suture technique was employed to suture the lateral ends of the donor site incision in 5 female patients undergoing DIEP breast reconstruction. The patients’ ages ranged from 39 to 56 years, with a mean age of 48.2 years. Four patients underwent primary breast reconstruction, while one patient underwent secondary reconstruction. Postoperatively, the donor site on the abdomen was routinely dressed with compression bandages.

Results

All 5 patients were followed up at one month postoperatively. The flaps survived successfully, and the donor site incisions healed primarily without complications. The skin at the lateral ends of the abdominal incisions appeared smooth, without any dog-ear deformity. No complications such as local concavity or infection were observed.

Conclusion

The half purse suture technique effectively eliminates the “dog-ear” deformity at the donor site incision of the DIEP flap.

Keywords

dog-ear deformity breast reconstruction DIEP flap half purse suture technique donor site aesthetics

Introduction

Breast reconstruction is a surgical procedure commonly performed after mastectomy (such as for breast cancer) or in cases of underdeveloped breasts or other breast defects.¹ The goal of breast reconstruction is to restore patient confidence and overall body image while providing breast symmetry and a natural appearance.² Common methods used in breast reconstruction include the use of autologous tissue flaps (such as from the abdomen, back, and buttocks) or breast implantation.

Autologous tissue flaps can be supplied with blood through vascular anastomosis or perforator vessels to ensure flap survival.^3,4 The surgical techniques for autologous tissue flap procedures have significantly advanced and improved over the past few decades. Early breast reconstruction surgeries utilized the pectoralis major muscle as a flap, transferring it to the breast area for reconstruction.⁵ However, this method had limitations in achieving breast shape and texture that matched natural breasts and could result in damage and functional limitations. The TRAM (Transverse rectus abdominis myocutaneous) flap, introduced in the 1980s, utilized the abdominal rectus muscle and skin tissue as donor tissue, with blood supply provided by connecting abdominal vessels.⁶ The TRAM flap provided a larger volume of tissue but was associated with potential complications such as impaired abdominal muscle function, abdominal hernias, and abdominal postoperative scarring. The GAP (Superior Gluteal Artery Perforator) and IGAP (Inferior Gluteal Artery Perforator) flaps, which utilize vascular perforators in the buttock region for breast reconstruction, are suitable for patients for whom abdominal tissue is unavailable or unsuitable.^7,8 The Deep Inferior Epigastric Perforator (DIEP) flap is a significant advancement in breast reconstruction in recent years.^9,10 It utilizes the perforators of the deep inferior epigastric artery in the lower abdomen to provide blood supply while preserving the rectus abdominis muscle. The advantages of the DIEP flap include the use of autologous tissue while avoiding the removal of abdominal muscles and related complications. However, patients undergoing DIEP flap reconstruction may sometimes experience “dog-ear” deformity on both sides of the abdominal scar,^11-13 affecting the aesthetic appearance of the abdomen. Correcting this deformity requires additional surgery, including traditional methods such as excision of the protruding skin and subcutaneous tissue of the “dog-ear” deformity followed by secondary closure of the incision or liposuction. However, the outcomes of these methods are often unsatisfactory, with only a transformation from a “large dog-ear” to a “small dog-ear.”

To address the “dog-ear” deformity, we propose the utilization of the half purse suture technique for the donor site incision in DIEP breast reconstruction surgery. This technique involves suturing the abdominal incision using a half purse-like closure (resembling the tying of a purse string), and it has been clinically applied in 5 cases from May to October 2022, yielding satisfactory results. The report is as follows.

Clinical Data

General Information

All patients in this cohort were females, with ages ranging from 39 to 56 years and a mean age of 48.2 years. Four cases involved primary breast reconstruction, all of which were diagnosed with invasive breast cancer. Among them, two cases were clinical stage I and two cases were clinical stage II, with a disease duration of 18 to 30 days. One case involved secondary reconstruction, performed one year after modified radical mastectomy for infiltrating carcinoma of the right breast. The distribution of surgical sides was as follows: left side (2 cases), right side (2 cases), and bilateral (1 case). Patients with prior abdominal surgical scars, active smokers, or BMI exceeding 30 kg/m² were excluded to minimize confounding factors affecting wound healing.

Surgical Procedure

Under general anesthesia, the patients were placed in a supine position. Simultaneous surgeries were performed for breast tumor excision and abdominal flap harvesting. When suturing the donor site incision after flap harvest, a zigzag incision was made to reduce tension. All four cases of primary breast reconstruction involved nipple-areola complex-preserving subcutaneous glandular tissue resection, sentinel lymph node biopsy, and deep inferior epigastric artery perforator (DIEP) flap breast reconstruction. Among them, two cases were left breast reconstruction, one case was right breast reconstruction, and one case was bilateral breast reconstruction. One case of secondary breast reconstruction involved scar excision of the right chest wall and abdominal deep inferior epigastric artery perforator (DIEP) flap breast reconstruction. The size of the harvested flap ranged from 28 cm × 10 cm to 36 cm × 14 cm.

For the donor site incision on both sides of the abdominal area, a nonabsorbable surgical suture (Size 1) was used for the half purse suture technique. The first suture needle was inserted from the upper part of the distal incision, passing through the external oblique muscle fascial layer diagonally and exiting from the deep layer of the fat layer. The second suture needle was inserted from the shallow layer of the fat layer, passing diagonally and exiting from the dermal layer. The third suture needle performed a semicircular suture within the dermal layer around the iliac crest incision. The fourth suture needle was inserted from the lower part of the distal incision, passing through the dermal layer diagonally and exiting from the superficial layer of the fat layer. The fifth suture needle was inserted from the deep layer of the fat layer, passing diagonally and exiting from the external oblique muscle fascial layer. Finally, a knot was tied in the external oblique muscle fascial layer, adjusting the tension based on the smoothness of the incision skin. Refer to Figure 1.

Figure 1.

Schematic Diagram of the Half Purse Suture Technique

Postoperative Management

After surgery, the patients were positioned in a flexed knee and hip position with the upper body elevated at an angle of 50 to 70°. The lower limbs were elevated at 45°, and a soft pillow was placed under the knees to reduce abdominal tension. An elastic abdominal binder was applied with compression dressing for over three months to prevent excessive tension and potential incisional dehiscence. The patients were allowed to ambulate and engage in activities of daily living 7 to 8 days postoperatively, with rehabilitation exercises commencing three weeks later.

Results

Statistical analysis was descriptive, including means and ranges for age, flap dimensions, and follow-up duration, consistent with the observational nature of a case series. No comparative analyses were performed due to the study design. At the 1-month postoperative follow-up, all 5 patients demonstrated excellent viability of the flaps, and the donor site incisions healed primarily without complications. The skin at the lateral ends of the abdominal incisions appeared smooth, without any “dog-ear” deformity. No complications such as local concavity or infection were observed as shown in Figure 2.

Figure 2.

A 48-Year-old Woman, With a Strong Desire for Breast Reconstruction, Having Thoroughly Understood the Details and Pros and Cons of Implant-Based Breast Reconstruction, Latissimus Dorsi Flap Breast Reconstruction, and DIEP Flap Breast Reconstruction, Voluntarily Opted for DIEP Flap Breast Reconstruction. (A) Preoperative Appearance of the Donor Site; (B). Immediate Postoperative Appearance of the Donor Site; (C). Appearance of the Donor Site at One Month Postoperatively

Discussion

“Dog-ear” deformity refers to the formation of a small bulge at the end of an incision after closure, typically due to excessive removal of skin at the incision’s endpoint and subsequent overlapping of the skin edges during closure.¹⁴ Healing of the donor site incision with a “dog-ear” deformity is one of the major complications affecting patient satisfaction in DIEP flap breast reconstruction.¹⁵ Historically, correction of the dog-ear deformity primarily involved secondary surgical procedures, in which excess skin was excised at a certain angle followed by readjustment of the closure.¹⁶ However, this approach resulted in additional incisions, formation of new scars, and increased complexity in the procedure. Miszkiewicz et al¹⁷ proposed the use of liposuction to address the “dog-ear” deformity in the donor site. This technique involved the application of negative pressure to remove a certain amount of adipose tissue from the dog-ear region, followed by moderate postoperative compression to achieve local smoothness and improve the aesthetic appearance of the donor site. Although this method has shown promising results, it still requires a secondary hospital admission.

The half purse suture technique we propose directly targets the underlying cause of the “dog-ear” deformity. Notably, all procedures were performed by a single surgical team to minimize variability in technique, and patients with BMI >30 kg/m² were excluded to reduce confounding effects of adipose distribution on outcomes. During the procedure, a semicircular suture is performed along the incision, and the circular contraction during knot tying causes the tissues surrounding the iliac crest incision to contract centripetally, thereby avoiding any protrusion. This method not only eliminates the need for a secondary hospital admission but also avoids additional incision scars. Based on the application of this technique in 5 clinical cases, we have summarized the following key points regarding the suture technique: (1) The first stitch in the half purse suture is crucial as its entry point determines the final location of the knot. (2) Attention should be paid to the direction of the second stitch, which should be obliquely upward. (3) The third stitch involves a semicircular suture, allowing for appropriate adjustment of the suture depth. This stitch, which is tied deeply, causes the surrounding tissues to contract downward and toward the center, making it the most critical step in eliminating the dog-ear deformity. (4) The fourth stitch is the reverse operation of the second stitch, and the direction of the needle should be oblique. (5) The fifth stitch must exit through the external oblique fascia to ensure that the knot is located within the deep tissues of the external oblique fascia. This approach has the advantage of placing the suture knot in the deep tissues, simultaneously allowing for traction and fixation of the surrounding tissues, effectively eliminating tissue protrusion, and ultimately achieving the goal of eliminating the dog-ear deformity. We believe that this suture technique is particularly suitable for cases where the angle of the distal incision of the donor site is excessively large. When this angle exceeds 40°, the distal incision becomes more circular-like, and during knot tying, the centripetal contraction of the tissues surrounding the iliac crest incision becomes more uniform, resulting in a smoother surface.

Limitations of this study include its small sample size (n = 5) and short-term follow-up period of one month, which may not fully capture late complications or scar maturation dynamics. Future research directions should focus on prospective randomized trials comparing this technique to traditional dog-ear correction methods, as well as multicenter studies with larger cohorts and long-term follow-up (eg, 6-12 months) to evaluate aesthetic durability.

Conclusion

The half purse suture technique is simple, fast, and capable of eliminating the “dog-ear” deformity in breast reconstruction surgery. While early outcomes are promising, long-term follow-up is required to assess the stability of results. When combined with the continuous application of an elastic abdominal binder with compression dressing, it achieves the desired outcome of a smooth incision at the iliac crest in the donor site. In the next phase, our team will conduct a randomized controlled trial comparing this technique to liposuction-based corrections, with a planned sample size of 30 patients and 12-month follow-up to confirm its clinical efficacy.

Footnotes

ORCID iD

Yuntao Li

Ethical Approval

This study was approved by the Ethics Committee of the Fourth Hospital of Hebei Medical University. All methods were carried out in accordance with relevant guidelines and regulations.

Consent to Participate

Informed consent was obtained from the patient for publication of this case report details.

Author Contributions

Study design: XW, LY, and YL; protocol implementation: XW, LY, HW, MW, KD, ZS, and YL; investigation and resources: ZS and YL; overall management: YL; manuscript draft: XW and LY. review and editing: MW, KD, ZS, and YL; all authors have read and agreed on the manuscript.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was funded by Hebei Provincial Health Commission Science and Technology Achievement Promotion Project (No.20201109).

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

Data is provided within the manuscript or supplementary information files.*

Appendix

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