Advantages of the Delayed–Immediate Microsurgical Breast Reconstruction: Extending the Choice

Background This study aimed to assess whether the reconstructed breast volume changed postoperatively following a deep inferior epigastric artery perforator (DIEP) flap. Methods Patients were included if they had undergone unilateral breast reconstruction with a DIEP flap at the two selected centers between April 2017 and September 2019. Serial 3-D surface imaging of both breasts was taken at 1, 3, 6, and 12 months postoperatively. The primary outcome was a volume ratio of the reconstructed to the contralateral breast. A linear mixed-effect model was used to evaluate whether the DIEP flap volume changed according to the postoperative time. Results A total of 74 patients were included in the analysis. The mean volume ratio of the reconstructed side compared to the contralateral breast at 1, 3, 6, and 12 months postoperatively were 106.9 %, 105.9 %, 108.7 %, and 107.6 %, respectively. In the linear mixed effect model, the volume ratio of the reconstructed breast did not change over time for immediate reconstructions (p = 0.376). However, there was an increase over time in delayed reconstructions (p = 0.043). Adjuvant radiation, chemotherapy, and hormone therapy did not influence the volume ratio of the reconstruced breast. Correlation analysis using repeatedly measured values showed that both reconstruced and healthy breast volumes had positive correlation with the patient’s body weight (p < 0.001). On the other hand, volume ratio of the breasts was not influenced by the patient’s body weight (p = 0.493). The volume ratio of the reconstructed breast significantly decreased in the upper inner (p = 0.003) and the upper outer (p = 0.006) quadrants, while increasing in the lower outer (p = 0.002) quadrant throughout the first-year postoperative period. Conclusion The volume ratio of the reconstructed to the contralateral breast does not decrease postoperatively following DIEP flap breast reconstruction.

Section: Accepted Manuscriptsupporting

confidence: 93%

Three-dimensional Volume Changes of the Reconstructed Breast Following DIEP Flap Breast Reconstruction

Lee

Park

et al. 2022

“…7 8 The reasons for this include (1) early reports of higher flap complication rates in immediate reconstruction followed by radiation, (2) limitations in treatment planning due to guidelines for postmastectomy radiation based on findings discovered at the time of mastectomy, and (3) potential for the flap to interfere with effective delivery of radiation to the chest wall. 9 10 11 12 22 23 24 25 26 The optimal timing of reconstruction after radiation remains an ongoing debate. Many believe that longer delays allow for recovery of acute inflammatory changes induced by radiation.…”

Section: Discussionmentioning

confidence: 99%

“…Although patient and treatment factors guide discussions and decisions for timing of reconstruction with anticipated radiation therapy (RT), delayed or delayed-immediate reconstruction remains the most common approach with anticipated radiation. 7 8 9 10 11 12 The prevailing assumption is that longer delays are needed to allow sufficient time for recovery of radiation treatment effects to tissues. This is supported by studies reporting higher complications rates when reconstruction is performed before 12 months.…”

mentioning

confidence: 99%

A Paradigm Shift: Outcomes of Early Autologous Breast Reconstruction after Radiation Therapy

Elver

Egan

Cullom

et al. 2022

Background Radiation creates significant challenges for breast reconstruction. There is no consensus regarding optimal timing for autologous reconstruction following radiation. This study explores clearly defined, shorter time intervals between completion of radiation and reconstruction than previously reported. Methods A retrospective review was performed on patients who underwent autologous reconstruction by five microsurgeons at an academic institution from 2009 to 2020. Cohorts were selected by time elapsed between radiation and autologous reconstruction including <3 months, 3 to 6 months, 6 to 9 months, 9 to 12 months, 12 to 24 months, and >24 months. Analysis compared baseline characteristics, operative details, complications, revision rates, and BREAST-Q scores. Analysis of variance was used for continuous variables and chi-square for discrete variables. Results In total, 462 radiated patients underwent 717 flaps. There were 69 patients at <3 months (14.9%), 97 at 3 to 6 months (21%), 64 at 6 to 9 months (13.9%), 36 at 9 to 12 months (7.8%), 73 at 12 to 24 months (15.8%), and 123 at >24 months (26.6%). Age, time from mastectomy, and failure of primary reconstruction were higher at >24 months (p < 0.001). There was no difference between cohorts in intraoperative complications in radiated or nonradiated breasts. There was no difference in acute and late postoperative complications between cohorts. Wound-healing complications in radiated sides were lowest at <3 months and 3 to 6 months (5/69 [7.3%] and 11/97 [11.3%], respectively) compared with other groups (18.8–22.2%) but did not reach significance (p = 0.11). More fat graft revisions occurred at <3 months (p = 0.003). Conclusion Reconstruction can be safely performed within 3 months after radiation without increases in intraoperative, acute, or late reconstructive complications.

“…29 30 31 There may also be cost savings related to choosing delayed-immediate as opposed to immediate DIEP flap reconstruction, as this option has been associated with shorter operative time, and this finding should be explored in future work. 32…”

Section: Discussionmentioning

confidence: 99%

Predictors and Consequences of Intraoperative Anastomotic Failure in DIEP Flaps

Chen

Varagur

Xun

et al. 2022

BACKGROUND: Successful intraoperative microvascular anastomoses are essential for deep inferior epigastric perforator (DIEP) flap survival. This study identifies factors associated with anastomotic failure during DIEP flap reconstruction and analyzes the impact of these anastomotic failures on post-operative patient outcomes and surgical costs. METHODS: A retrospective cohort study was conducted of patients undergoing DIEP flap reconstruction at two high-volume tertiary care centers from January 2017 to December 2020. Patient demographics, intraoperative management, anastomotic technique, and post-operative outcomes were collected. Data were analyzed using Student’s t-tests, chi-square analysis, and multivariate logistic regression. RESULTS: Of the 270 patients included in our study (mean age 52, majority Caucasian [74.5%]), intraoperative anastomotic failure occurred in 26 (9.6%) patients. Increased number of circulating nurses increased risk of anastomotic failure (Odds Ratio (OR) 1.02, 95% Confidence Interval (CI) 1.00-1.03, P<0.05). Presence of a junior resident also increased risk of anastomotic failure (OR 2.42, 95% CI 1.01-6.34, P<0.05). Increased surgeon years in practice was associated with decreased failures (OR 0.12, CI 0.02-0.60, P<0.05). Intraoperative anastomotic failure increased the odds of post-operative hematoma (OR 8.85, CI 1.35-59.1, P<0.05) and was associated with longer operating room times (bilateral DIEP: 2.25 hours longer, P<0.05), longer hospital stays (2.2 days longer, P<0.05), and higher total operating room cost ($28,529.50 versus $37,272.80, P<0.05). CONCLUSION: Intraoperative anastomotic failures during DIEP flap reconstruction are associated with longer, more expensive cases and increased rates of post-operative complications. Presence of increased numbers of circulators and junior residents was associated with increased risk of anastomotic failure. Future research is necessary to develop practice guidelines for optimizing patient and surgical factors for intraoperative anastomotic success.