Conservative mastectomies and Immediate-DElayed AutoLogous (IDEAL) breast reconstruction: the DIEP flap

Abstract

Background: With the development of conservative mastectomies, there are an increasing number of women seeking immediate implant based and autologous breast reconstruction. Despite the oncologic safety of the procedures, the focus will be on the timing of reconstruction.

Methods: Our plastic surgery unit is focused primarily on autologous breast reconstruction and is part of an interdisciplinary breast center. We offer immediate breast reconstruction (IBR) with autologous tissue for patients with positive BRCA 1 and 2, ductal carcinoma in situ (DCIS), invasive cancer without margin problems to the skin, as well as to correct poor oncologic and aesthetic breast conserving therapy (BCT) outcomes. In the majority of cases we prefer an Immediate-DElayed AutoLogous (IDEAL) breast reconstruction concept with a two-stage procedure.

Results: Over the last 10 years we performed more than 1,600 breast reconstructions with free flaps, performing the deep inferior epigastric perforator (DIEP) flap as our first choice for autologous tissue. We recommend IDEAL breast reconstruction, however approximately 15% of our cases are immediate one stage conservative mastectomies and breast reconstruction with the DIEP flap.

Conclusions: For immediate reconstruction, the aesthetic outcome should not take precedence over oncologic considerations. Immediate one-stage, breast reconstruction with autologous tissue can be offered to the suitable patients which is most likely a healthy women with a small-to-medium sized non ptotic breast receiving a conservative mastectomy. In all other cases, we recommend an IDEAL breast reconstruction approach in order to achieve a final result that is both satisfyingly pleasing and oncologically safe.

Keywords: Mastectomy; deep inferior epigastric perforator flap (DIEP flap); immediate-delayed reconstruction; oncoplastic surgery.

Figure 1

Timing and concept of breast reconstruction with the DIEP flap. DIEP, deep inferior epigastric perforator; DCIS, ductal carcinoma in situ; BCT, breast conserving therapy; XRT, radiation therapy; NSM, nipple sparing mastectomy; SSM, skin sparing mastectomy.

Figure 2

A 45-year-old woman with invasive breast cancer on the right side. Preoperative view.

Figure 3

Result 3 months postoperatively after SSM + immediate bilateral breast reconstruction with a DIEP flap. SSM, skin sparing mastectomy; DIEP, deep inferior epigastric perforator.

Figure 4

Result 3 years postoperatively after nipple reconstruction with star flaps and tattooing of the areolar complex.

Figure 5

A 54-year-old woman with previous BCT and poor cosmetic outcome after radiation therapy and chemo therapy, immediate delayed concept. BCT, breast conserving therapy.

Figure 6

Same patient 6 months postoperatively.

Figure 7

Nipple sparing mastectomy with total breast tissue removement and preservation of blood supply to the skin.

Figure 8

Skin necrosis after immediate reconstruction due to poor skin perfusion after mastectomy.