Deep Inferior Epigastric Artery Perforator Flap Breast Reconstruction in Patients With Previous Bariatric Surgery: Is It Safe and Feasible?

BACKGROUND: Obesity is widely recognized as a major health concern and a leading cause of preventable death. The correlation between obesity and breast cancer has been thoroughly described by several authors. Bariatric surgery is often associated with redundant abdominal tissue, often leading patients to consider body-contouring procedures. Autologous tissue breast reconstruction using the deep inferior epigastric artery perforator (DIEP) flap has advantages because it is tissue that is normally discarded during postbariatric body contouring. METHODS: We conducted a retrospective chart review of 18 DIEP flaps performed by the senior author in 9 patients for breast reconstruction between February 2008 and May 2013. All patients underwent mastectomies. All patients underwent bariatric surgery preceding breast reconstruction. Breast reconstruction was performed immediately in 13 cases and delayed in 5 cases. RESULTS: Mean age of the study population was 44.6 years (range, 41-57 years). The mean maximum body mass index of the patients was 44 (range, 37.6-52.1), and the mean current body mass index at the time of the reconstruction was 30.7 (range, 24.3-38.1). No intraoperative complications were reported. No fascia or muscle was taken during flap dissection. Mean operative time was 632 minutes (range, from 480 to 750 minutes). Average hospital stay was 4 days. No partial or total flap loss was reported. There were no postoperative hernias or bulges at the abdominal donor site. CONCLUSIONS: This series represents the largest group of patients undergoing DIEP flap breast reconstruction after bariatric surgery. In the hands of experienced microsurgeons, breast reconstruction with the DIEP flap in postbariatric patients represents a low-risk option with high satisfaction.

The Nipple-Areola Preserving Mastectomy: A Multistage Procedure Aiming to Improve Reconstructive Outcomes following Mastectomy.

UNLABELLED: Ischemia of the nipple-areola complex (NAC) and periareolar tissue is commonly seen following tissue-preserving mastectomies for small invasive and noninvasive cancers. The nipple-areola preserving mastectomy is a multistage procedure in which the NAC and central mastectomy flap tissue is surgically delayed to improve the survivability in patients undergoing mastectomies followed by reconstruction. METHODS: We conducted a retrospective chart review of 20 patients undergoing the 2-stage nipple-areola preserving mastectomy: the first stage comprised undermining the NAC and raising the breast skin flaps, with placement of a silicone sheet in the dissected pocket. The second stage followed 2-3 weeks after the NAC delay, with patients undergoing nipple-sparing mastectomies. RESULTS: Mean age was 46.2 years (range, 23-59 years). Indications included breast cancer in 18 patients and BRCA gene mutation prophylaxis in 2 patients. None were actively smoking. Mean time between delay of flaps and breast reconstructions was 16 days (range, 10-35 days). One patient underwent bilateral nipple resection at the time of mastectomies due to a subareolar nipple biopsy positive for ductal carcinoma in situ. One patient underwent left nipple excision after a skin nipple biopsy was positive for metaplasia. No signs of NAC vascular compromise were observed in any of the cases. CONCLUSIONS: Our 2-stage approach benefits patients undergoing nipple-sparing mastectomy, especially those at high-risk, by safely increasing survivability of the native breast skin envelope and NAC, while improving oncologic outcomes by identification of subareolar malignancies and sentinel node status before mastectomy and reconstruction.

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.