Comparison of Immediate versus Delayed DIEP Flap Reconstruction in Women Who Require Postmastectomy Radiotherapy

Abstract

Background: The authors investigated aesthetic outcome and patient satisfaction in women who have undergone deep inferior epigastric artery perforator (DIEP) flap reconstruction in the setting of postmastectomy radiotherapy. Patients who underwent DIEP flap reconstruction without postmastectomy radiotherapy were the control group.

Methods: Participants who had undergone DIEP flap reconstruction between September 1, 2009, and September 1, 2014, were recruited, answered the BREAST-Q, and underwent three-dimensional surface-imaging. A panel assessed the aesthetic outcome by reviewing these images.

Results: One hundred sixty-seven women participated. Eighty women (48 percent) underwent immediate DIEP flap reconstruction and no postmastectomy radiotherapy; 28 (17 percent) underwent immediate DIEP flap reconstruction with postmastectomy radiotherapy; 38 (23 percent) underwent simple mastectomy, postmastectomy radiotherapy, and DIEP flap reconstruction; and 21 (13 percent) underwent mastectomy with temporizing implant, postmastectomy radiotherapy, and DIEP flap reconstruction. Median satisfaction scores were significantly different among the groups (p < 0.05). Post hoc comparison demonstrated that women who had an immediate DIEP flap reconstruction were significantly less satisfied if they had postmastectomy radiotherapy. In women requiring radiotherapy, those undergoing delayed reconstruction after a simple mastectomy were most satisfied, but there was no significant difference between the immediate DIEP flap and temporizing implant groups. Median panel scores differed among groups, being significantly higher if the immediate reconstruction was not subjected to radiotherapy. There was no significant difference in panel assessment among the three groups of women who had received radiotherapy.

Conclusions: Patients who avoid having their immediate DIEP flap reconstruction irradiated are more satisfied and have better aesthetic outcome than those who undergo postmastectomy radiotherapy. In women requiring radiotherapy and who wish to have an immediate or "delayed-immediate" reconstruction, there were no significant differences in panel or patient satisfaction. Therefore, immediate DIEP flap reconstruction or mastectomy with temporizing implant then DIEP flap surgery are acceptable treatment pathways in the context of post-mastectomy radiotherapy.

Trial registration: ClinicalTrials.gov NCT03072316.

Fig. 1.

Images produced using the three-dimensional imaging system include (above, left) anteroposterior, (above, right) lateral, (center, left) craniocaudal, (below, right) oblique, and (below, left) caudocranial.

Fig. 2.

Diagram of recruitment.

Fig. 3.

Representative images from each of the four groups. Please note that the panel assessed moving three-dimensional images not the two-dimensional images shown here. (Above, left) Patient with a score of 8.5 from group A: skin-sparing mastectomy with immediate DIEP flap reconstruction without postmastectomy radiotherapy (median score, 8). (Above, right) Patient with a score of 7.25 from group B: skin-sparing mastectomy with immediate DIEP flap reconstruction and postmastectomy radiotherapy (median score, 7.3). (Below, left) Patient with a score of 7.0 from group C: simple mastectomy (no skin preservation), postmastectomy radiotherapy, and delayed DIEP flap reconstruction (median score, 7.3). (Below, right) Patient with a score of 7.75 from group D: skin-sparing mastectomy and preservation of skin flaps with temporizing implant, postmastectomy radiotherapy, and later DIEP reconstruction (median score, 7.8).

Fig. 4.

Box-and-whisker plot demonstrating global panel assessment scores according to different treatment pathways. The horizontal line through the center of each box represents the median score, outer horizontal lines of each box represents upper and lower quartiles, and the ends of the vertical lines represent minimum and maximum scores. There was a significant difference between A and B. imm, immediate; PMRT, postmastectomy radiotherapy; mx, mastectomy; TI, temporizing implant.

Fig. 5.

Box-and-whisker plot demonstrating Satisfaction with Breasts according to different treatment pathways. The horizontal line through the center of each box represents median score, outer horizontal lines of each box represent upper and lower quartiles, and the ends of the vertical lines represent minimum and maximum scores. There was a significant difference between A and B, and B and C. imm, immediate; PMRT, postmastectomy radiotherapy; mx, mastectomy; TI, temporizing implant.