Systematic review of buried flap reconstructions after nipple-sparing mastectomy.

Background: Although autologous reconstruction after nipple-sparing mastectomy (NSM) is well established, the subset of buried-free flap reconstructions remains less well characterised. With evolving surgical techniques understanding the safety, efficacy, and outcomes of buried-free flap reconstructions is increasingly important. Aim: To review recent literature regarding autologous buried-free flap reconstructions post mastectomy, including demographics, indications, outcomes and complications. Methods: A search of PubMed and Medline databases was performed using the keywords "deep inferior epigastric perforator flap", "DIEP", "deep inferior epigastric flap", "free flap", "transverse upper gracilis", "TUG", "bury", "buried", "burying", "autologous breast reconstruction", "autologous reconstruction", "breast reconstruction", and "nipple-sparing mastectomy" using a 3-component search along with the Boolean operators 'AND' and 'OR'. Results: Seventy-five studies were retrieved with 12 meeting the inclusion criteria. Four studies directly compared buried and non-buried flaps. A total of 385 patients underwent 585 buried-free flap reconstructions. These were predominantly DIEP (70.8%), immediate (76.8%) and post-NSM (72.6%). Flap loss was similar (1.5%vs 1.8%; partial 0.3% vs 0.9%). Return-to-theatre rates were 7.5% for buried and 9.1% for non-buried flaps. Anastomotic complications were similar (2.8%vs 2.6%). Buried flaps demonstrated higher rates of fat necrosis (4.1%vs 2.1%) and infection (4.5%vs 1.5%), while non-buried flaps had higher wound dehiscence rates (5.9%vs 4.6%). Revision procedures were more common in buried flaps (59.9%vs 49.2%). Conclusions: Buried-free flap reconstruction following NSM is safe and technically feasible, with comparable complication rates compared to conventional techniques. Standardised monitoring and patient-reported outcomes are needed to optimise selection and wider adoption.