Autologous dermal flap techniques beyond inferior dermal flap coverage in implant-based breast reconstruction: A systematic review.

BACKGROUND: While inferior dermal flap (IDF) techniques are gaining popularity for implant-based reconstruction (IBBR), a range of autologous dermal flap (ADF) modifications have been described that serve purposes beyond standard implant coverage. METHODS: Following PRISMA guidelines, we systematically searched six databases from January 1, 2020, to July 22, 2025, for studies on autologous dermal flap applications beyond standard IDF coverage. We excluded free flaps, IDF-only, subpectoral-only, nipple-areolar complex-only, and ADM/synthetic mesh-based-only reconstructions. RESULTS: Out of 15,678 initial articles, 17 met the inclusion criteria encompassing 357 patients and 535 breasts across 12 retrospective studies, 3 case reports, 1 prospective case series, and 1 randomized controlled trial. Techniques identified included nipple-carrying autologous dermal flaps using various pedicle configurations, meshed autologous dermis, skin-island carrying flaps, contralateral dermal grafting, autodermal fillers, and combinatorial approaches. Major complication rates varied substantially by technique: complete NAC necrosis ranged from 0% to 31.5% depending on pedicle breadth, with broader pedicles consistently associated with lower necrosis rates. Major complications across non-nipple-carrying techniques ranged from 0% to 20%. CONCLUSIONS: This review identifies and categorizes a spectrum of autologous dermal flap modifications beyond standard inferior dermal flap coverage, demonstrating that broader pedicle configurations are consistently associated with reduced NAC necrosis rates. The overall evidence base remains retrospective and heterogeneous, and prospective trials incorporating patient-reported outcomes, cost analyses, and stratification by radiation exposure are needed to establish the role of these techniques relative to ADM and synthetic mesh in oncologic breast reconstruction.