Immediate Post-Mastectomy Hybrid Reconstruction: DIEP Flap Plus Implant
IntroductionThin women with moderate to large breasts present a clinical challenge for post-mastectomy breast reconstructions. Autologous reconstructions that use a patient’s own body tissue, such as DIEP flap and TRAM flap surgeries, offer the most natural reconstructed breasts. However, many thin patients, particularly those undergoing a double mastectomy, often have insufficient abdominal tissue for a purely DIEP flap or TRAM flap reconstruction.
Traditionally, this subset of thin, large-breasted women have selected an LD flap surgery, which uses a patient’s latissimus dorsi (upper back) muscle to reconstruct the breast flap. In a later surgery, an implant is placed inside the new breast flap to add the desired volume. Unfortunately, many young, healthy, active women are ultimately disappointed with both the scarring and loss of muscle function associated with LD flap surgeries.
In contrast, DIEP flap surgeries, which utilize fatty abdominal tissue to reconstruct the breast area, do not generally result in extensive scarring. DIEP flap incisions can generally be hidden inside the bikini line, and the procedure can also result in improved post-operative abdominal contour. In the past, however, slender women with inadequate abdominal tissue have not generally been offered the opportunity to undergo DIEP flap reconstruction.In recent years, we have developed a successful hybrid surgery that combines a DIEP flap procedure with the immediate insertion of a breast implant. We believe that this hybrid DIEP flap surgery is a viable and superior reconstructive option for thin patients who prefer autologous reconstructions. This paper presents the first documented case studies of six patients who underwent hybrid breast reconstructions, combining DIEP flap surgery with the immediate placement of silicone gel implants.
Patients and MethodsOur study included six patients who received implants plus DIEP flap reconstructions in NYC's Mount Sinai Hospital between 2007 and 2009. Five of the six patients received bilateral reconstructions.
Patients were initially evaluated in the private offices of top plastic surgeons in NYC Doctors Leo Keegan and Dr. Carlin Vickery, and all options for post-mastectomy breast reconstruction were discussed in detail. All of the patients selected for the procedure were initially considered to be good candidates for a DIEP flap surgery, but ultimately had insufficient abdominal tissue for a purely autologous surgery. All six patients were classified as thin or normal weight based on Body Mass Index (BMI) calculations. The patients’ BMI ranged from 18.0 to 23.5, with an average BMI of 21.8. (A BMI of 25 is considered the top of the normal weight range.) The patients ranged from 37 to 60 years old, with an average age of 47. All patients were nonsmokers at the time of surgery, though three patients were ex-smokers who had quit at least nine months prior to the date of the surgery.
Three of the six patients requested augmentation relative to their pre-mastectomy breast size, and were considered ideal candidates for DIEP flap surgery with an implant for added volume. Two additional patients had loose abdominal skin, making them reasonable candidates for autologous reconstruction, but they simply had insufficient abdominal tissue to achieve an acceptable post-operative breast mound. One patient had previously undergone bilateral breast reconstruction with implants, and she developed complications in one of her reconstructed breasts. She chose DIEP flap surgery as a “salvage” procedure, but an implant was necessary to achieve symmetry with the other reconstructed breast.In all six patients, the DIEP flap procedure and insertion of the implant occurred immediately after the mastectomy. In all patients, smooth round gel implants were used, and all six patients continue to receive regular post-operative consultations in the offices of plastic surgery New York Doctors Keegan and Dr. Vickery. When this article was written, patients had been monitored for 6 to 34 months after their surgeries.
Results and DiscussionAll patients were satisfied with their post-operative breast reconstructions and abdominal contour at the time of their latest follow-up consultations. There were no cases of implant infection requiring antibiotic treatment, implant removal, or implant exchange. The average length of postoperative hospital stay was 5 days, and all patients remained in the hospital for 4-6 days after their surgery.
These results suggest that hybrid DIEP flap surgeries with implants provide a safe, viable solution for thin women who prefer a natural look to their reconstructed breasts. Because of the natural tissue provided by the DIEP flap procedure, implants have a minimal impact on the overall shape of the reconstructed breast. If performed by a skilled team of surgeons, a DIEP flap reconstruction with implants can be tailored to replicate the appearance and feel of a natural breast. The DIEP flap procedure creates a comfortable skin envelope for the implant, and patients can expect to enjoy long-lasting results, with a relatively low risk of complications.Ideal candidates for hybrid DIEP flap surgery with implants are likely to be thin women who prefer the natural look and feel of autologous breasts, but lack sufficient abdominal tissue for a purely DIEP flap surgery. This procedure might also be appropriate for women who wish to avoid the loss of muscle function associated with LD (latissimus dorsi) flap surgeries. Finally, women who seek an augmentation of their breast size relative to their pre-mastectomy size may benefit from hybrid DIEP flap surgery.
ConclusionThis study, though small, demonstrates that hybrid DIEP flap surgeries with implants can be performed safely. Hybrid DIEP flap reconstruction can be used successfully in thin women who request augmentation relative to their pre-mastectomy breast size, but have insufficient tissue for purely autologous reconstruction. Women with these characteristics have traditionally been offered LD or TRAM flap reconstructions with implants, and we believe that the hybrid DIEP flap procedure offers an outstanding alternative with a low incidence of complications.
About the SurgeonsDr. Leo Keegan and Dr. Carlin Vickery are New York’s longest-tenured surgical team specializing in breast reconstruction surgery. In addition to their groundbreaking work with hybrid DIEP flap reconstructions, NYC Doctors Keegan and Dr. Vickery perform a full spectrum of breast reconstruction surgeries, including LD flap, TRAM flap, SIEA flap, and implant-based reconstructions. Dr. Keegan and Dr. Vickery are among a select group of doctors who are board-certified in both general surgery and plastic surgery, and both doctors have decades of experience using microsurgical techniques. Data for this article was compiled by Dr. Daniel Maman and Dr. George Xipoleas, both of whom also participated in the surgical process.