Delayed Mammoplasty with Silicone Gel Implants following DIEP Flap Breast Reconstruction.

UNLABELLED: The deep inferior epigastric artery perforator (DIEP) flap is a state-of-the-art option for breast reconstruction. However, thin patients with medium- to large-size native breasts are not ideal candidates due to the limited amount of available tissue. We reviewed our experience utilizing the DIEP flap in combination with prosthetic implants.
METHODS: We conducted a retrospective chart review of 7 patients, totaling 11 implants, who underwent breast reconstruction with the DIEP flap and subsequent mammoplasty. All cases underwent previous mastectomies. No implant placement was offered at the time of their DIEP flap reconstruction. Immediate breast reconstruction with the DIEP flap was performed in 9 cases, whereas 2 required delayed reconstruction secondary to postmastectomy radiotherapy. No patients received postreconstruction radiotherapy. Breast asymmetry and inadequate volume were the primary indications for mammoplasty. For all cases, we used smooth, round silicone gel implants, which were placed in the subpectoral region.
RESULTS: Mean age was 43 years. One patient was actively smoking. Four patients underwent bilateral implant placement. The mean time of delay between breast reconstruction and mammoplasty was 61 weeks. Average volume of silicone implants was 229 mL. A medial pedicle vertical mastopexy was performed in 1 patient on a nonreconstructed breast to achieve symmetry. Five patients underwent nipple reconstruction. All patients underwent delayed mammoplasty without intraoperative complications and good aesthetic results.
CONCLUSIONS: Delayed mammoplasty following DIEP flap breast reconstruction is a safe and feasible procedure for patients who seek an aesthetic and natural-looking breast but lack adequate abdominal tissue.

Improvements in the free flap breast reconstruction techniques resulted in the development of the deep inferior epigastric artery perforator (DIEP) flap.[1-6] However, patients who are thin with medium- to large-size breasts are not ideal candidates for this type of reconstruction due to the limited amount of available abdominal tissue required for desired size and symmetry. Before the advent of the DIEP flap, the solution to overcome a thin body habitus without sacrificing aesthetics in this patient population was the use of the latissimus dorsi flap or the transverse rectus abdominis myocutaneous flap in combination with an implant.[7-11] These procedures can provide the natural appearance of autologous reconstruction combined with the volume of the prosthesis. In addition, it has been shown that complications are reduced when an implant reconstruction is combined with an autologous flap.[12] Likewise, breast reconstruction by autologous fat grafting has emerged as a practical option due to its versatility and minimal complications, although its use has been limited to the correction of small volume or contour deformities in patients with sufficient volume of donor sites.

A number of options can be considered for thin patients who wish to maintain or increase their breast size or whose abdominal tissue is not adequate for the desired projection. However, these procedures usually require repositioning and team approaches. Gluteal artery perforator flaps can provide ample tissue alone for thin patients, but can be more technically demanding and can result in challenging donor-site deformities. The body lift perforator flap offers a technically demanding solution for this patient population and does not require the use of implants. However, it requires supine and prone positioning and longer operative times.[13]

In our experience, a safe, simple solution is the use of the DIEP flap in combination with prosthetic implants. The perfect candidates for mammoplasty following a DIEP flap include those patients with a thin body habitus and large-size breasts, especially in the cases of bilateral breast reconstruction, where the amount of abdominal tissue is inadequate to create 2 aesthetically pleasing breasts. We reviewed our experience performing a combined, 2-stage reconstruction using the DIEP flap with prosthetic implants to improve the aesthetic results in the postmastectomy population.

PATIENTS AND METHODS

After institutional review board approval, 184 consecutive patients who underwent breast reconstruction with the DIEP flap from July 2007 to November 2012 were identified. A total of 314 flaps were performed by either 1 of 2 surgeons in a single practice group (54 patients required unilateral reconstruction, whereas 130 required bilateral reconstruction). We then gathered the data of patients who underwent mammoplasty following DIEP flap reconstruction; 7 patients, totaling 11 implants, were selected for our study and retrospectively reviewed. Variables such as age, American Society of Anesthesiologists score, preoperative and postoperative radiotherapy (RT), indications for mammoplasty, implant details (type, size, and location), complications, and postoperative visits were collected. Table 1 summarizes the data collection.

Table 1.

Patient Data

No patients were offered implant placement at the time of their DIEP flap reconstruction. The patients were counseled in detail about the risks of implant placement as a second-stage reconstruction including devascularization of the flap with subsequent loss and an increased risk of revisionary surgery or capsular contracture. During the first stage, immediate breast reconstruction with the DIEP flap was performed in 9 cases, whereas 2 required delayed reconstruction secondary to postmastectomy radiation therapy. One patient who underwent immediate reconstruction had a previous partial mastectomy followed by RT. Breast asymmetry and inadequate volume were the primary indications for mammoplasty. Smooth, round silicone gel implants were used in all the patients, as they provide the most natural feel. Although we do not use implant sizers, the implant volume was chosen upon chest dimensions, always aiming to spare approximately 1 cm to avoid added pressure to the flap pedicle. Following dissection under direct vision of the subpectoral pocket, implants were placed using a Keller funnel. Partial release of the pectoralis muscle was performed as needed, by inferior dissection perpendicular to the muscle fibers, as placing the implant under the pectoralis muscle proved arduous in some cases, notably in those patients with previous radiation. Full-thickness release of the pectoralis muscle was not needed in any case

Details of additional procedures and intraoperative findings during the second-stage reconstruction with the implant placement were documented. Information regarding intraoperative and postoperative complications was collected. During follow-up, patients provided a subjective scale of overall satisfaction.

RESULTS

Seven patients underwent delayed implant-based mammoplasty following reconstruction with the DIEP flap, totaling 11 implants. Mean age of the group was 43 years (range between 33 and 52 years), with an American Society of Anesthesiologists score of 1 in all cases. Only 1 patient (no. 2) was actively smoking. Four patients underwent bilateral breast reconstruction. In all patients, the internal mammary was utilized as the recipient vessel. Three patients received RT before the first stage of the reconstruction. No patients received postreconstruction RT. Superficial necrosis of the mastectomy skin flaps in 1 patient was the only complication following the first stage of reconstruction. The mean time of delay between DIEP flap breast reconstruction and mammoplasty was 61 weeks (range between 19 and 127 weeks). In 3 patients, mammoplasty was indicated due to asymmetry. Two patients presented with postreconstruction inadequate volume when compared to their native breasts (1 patient also had deformities to the superior poles in both breasts), and a fuller appearance was the primary concern in the remaining 2 patients.

Smooth, round silicone gel implants were used in all cases, with an average volume of 229 mL (range between 125 and 304 mL). The implant was placed through an inframammary fold incision or a vertical incision depending on the preexisting scar pattern. A medial pedicle vertical mastopexy was designed in the native contralateral breast of 1 patient to achieve symmetry. Five patients underwent nipple reconstruction. All patients underwent delayed mammoplasty without intraoperative complications and good aesthetic results. Mean follow-up period was 37 weeks (range between 4 and 120 weeks). There were no postmammoplasty complications and all patients were satisfied.

CASE REPORTS

Case 1

A 49-year-old woman with a history of left-sided ductal carcinoma underwent left mastectomy. Delayed reconstruction with the DIEP flap was performed after she underwent RT and chemotherapy. She was concerned about the inadequate volume in the reconstructed breast, and she sought to improve her appearance. To obtain more volume, she underwent mammoplasty following a 13-week postoperative period with a 340-cm3 silicone gel implant placed in the subpectoral region; she underwent nipple reconstruction. Patient satisfaction was achieved and no complications occurred (Fig. 1).

Fig. 1.

A, A 49-year-old woman with delayed DIEP flap breast reconstruction following radiation and chemotherapy. B, Postoperative result with a 340-mL silicone gel implant and nipple reconstruction.

Case 2

A 46-year-old woman with history of multifocal ductal carcinoma underwent bilateral skin-sparing mastectomies with immediate reconstruction using the DIEP flap. Postoperatively, the patient was satisfied with the results, but she desired a fuller appearance. She underwent mammoplasty 97 weeks after breast reconstruction; 304-cm3 silicone gel implants were placed in the subpectoral region bilaterally. She also underwent nipple reconstruction. There were no complications. Postoperatively, the patient was highly satisfied with the results (Fig. 2).

Fig. 2.

A, A 46-year-old woman with multifocal ductal cancer. B, Underwent bilateral DIEP flap breast reconstruction following skin-sparing mastectomies. C, Postoperative results with 340-cm3 silicone gel implants and additional nipple reconstructions.

Case 3

A 37-year-old woman with history of left-sided breast cancer status post mastectomy and RT underwent delayed left breast reconstruction with the DIEP flap. She also underwent a prophylactic mastectomy with immediate right-sided reconstruction. Due to inadequate volume, she sought further options for an improved appearance. She underwent bilateral revisionary surgery 54 weeks following reconstruction. A subpectoral 265-cm3 silicone gel implant was placed in the left breast, whereas a 210-cm3 implant was required for the right breast. The patient also underwent nipple reconstruction. The patient tolerated the procedure without complications. Due to the history of RT, the left breast implant settled higher than the right postoperatively; nonetheless, she was highly satisfied with the results (Fig. 3).

Fig. 3.

A 37-year-old woman with history of bilateral mastectomies (A) and delayed DIEP flap breast reconstruction (B). C, Postoperative results with a left-sided, 265-cm3 and right-sided, 210-cm3 silicone gel implants, with additional nipple reconstructions.

DISCUSSION

The advantages of the DIEP flap over other reconstructive techniques have been extensively reported, and it is an excellent choice for autologous reconstruction given its low rate of donor-site complications when compared to other autologous techniques.[14-16] The combined approach of autologous tissue and prosthetic implants or expanders has been advocated by Kronowitz et al, Spear and Wolfe, and Serletti and Moran[7,9,10] to improve appearance and symmetry in thin patients with large premastectomy breast volumes.[8,10]

The subcutaneous fat of the DIEP flap closely resembles the appearance and texture of the natural breast, giving an aesthetically pleasing shape to the reconstruction, whereas the secondary placement of a silicone gel implant provides the desired volume. As opposed to other tissue-based reconstruction techniques like the latissimus dorsi flap, where a larger implant is required due to the reduced volume provided by the flap, smaller implants can achieve a fuller look when combined with the DIEP flap (average size in our cases was 229 mL), thus possibly decreasing the rate of complications that may arise from mechanical pressure from the underlying implant.

For all of our patients, we chose a 2-stage breast reconstruction with delayed mammoplasty. Kronowitz et al[7] and Spear and Wolfe[9] noted that immediate mammoplasty of the reconstructed breast with the transverse rectus abdominis myocutaneous flap was prone to complications, including flap failure and an increased rate of infection. Others[17] have reported primary placement of implants following breast reconstruction with the DIEP flap, supporting the idea that immediate implant placement could reduce unintentional damage to the pedicle by avoiding the need for a second surgery, with no statistically significant results. Furthermore, in their series, 3 flaps with primary mammoplasty presented with complications, including 2 cases of partial flap necrosis.

We believe that a delayed approach could prevent postoperative flap complications. DIEP flap reconstruction is a long and technically demanding procedure. Immediate implant placement leads to additional operative time, increasing the chance for infection and other postoperative complications. In our experience, the majority of patients undergo a second surgery for revision and/or nipple reconstruction, and this is an ideal time to undergo implant placement. We believe that an approximate waiting period of 4 months is an ideal time frame between both stages, as it provides sufficient time to decrease the inflammation caused by the reconstruction and the revascularization of the flap based on the pectoralis interface. Additional precautions are taken in the cases of postreconstructive RT, where waiting periods could take up to 1 year.

Literature in regard to mammoplasty suggests that a subpectoral placement of the implant may reduce the incidence of capsular contracture,[18] whereas concealing any contour deformities that may arise with time. Furthermore, a submuscular plane seems like an ideal choice, as it offers protection to the perforators by keeping them above the muscle. Also, in the event of a problem with the pedicle, the pectoralis could provide revascularization to the substance of the flap and prevent complete loss of the flap, which would be unlikely to occur with placement of the implant immediately deep to the DIEP flap itself. Capsular contracture is a common complication that has been extensively reported.[7-9] However, we did not find any evidence in our relatively short follow-up period.

CONCLUSIONS

Increased options in the field of reconstruction with autologous tissue will improve our ability to re create the premastectomy appearance of the breast. Delayed mammoplasty following DIEP flap breast reconstruction is a safe and feasible procedure for patients who seek an aesthetic and natural-looking breast but lack adequate abdominal tissue. Larger cohorts comparing the outcomes of immediate versus delayed following breast reconstruction with the DIEP flap are needed to assess their pearls and pitfalls, in addition to the subpectoral versus subflap approach for implant placement.