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J Reconstr Microsurg
DOI: 10.1055/a-2540-1154
Original Article

Effect on Timing of Free Flap Breast Reconstruction on Mastectomy Skin Necrosis

Shahnur Ahmed 
1   Division of Plastic Surgery, Indiana University School of Medicine, Indianapolis, Indiana
,
Jordan Crabtree
1   Division of Plastic Surgery, Indiana University School of Medicine, Indianapolis, Indiana
,
Kasra N. Fallah
1   Division of Plastic Surgery, Indiana University School of Medicine, Indianapolis, Indiana
,
Ethan J. Rinne
1   Division of Plastic Surgery, Indiana University School of Medicine, Indianapolis, Indiana
,
Luci Hulsman
1   Division of Plastic Surgery, Indiana University School of Medicine, Indianapolis, Indiana
,
Carla S. Fisher
2   Division of Breast Surgery, Indiana University School of Medicine, Indianapolis, Indiana
,
Kandice K. Ludwig
2   Division of Breast Surgery, Indiana University School of Medicine, Indianapolis, Indiana
,
Rachel M. Danforth
1   Division of Plastic Surgery, Indiana University School of Medicine, Indianapolis, Indiana
,
Mary E. Lester
1   Division of Plastic Surgery, Indiana University School of Medicine, Indianapolis, Indiana
,
Aladdin H. Hassanein
1   Division of Plastic Surgery, Indiana University School of Medicine, Indianapolis, Indiana
› Author Affiliations Funding None.
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Abstract

Background Deep inferior epigastric perforator (DIEP) flap is a common autologous breast reconstruction option. DIEP flap may be performed immediately on the day of mastectomy (immediate DIEP) or at a later date typically following placement of a tissue expander during mastectomy (delayed-immediate DIEP). Preparing internal mammary vessels during microsurgical anastomoses involves prolonged retraction of the breast skin flaps, which can increase tension on acutely ischemic mastectomy skin. The purpose of this study is to investigate whether DIEP flap timing has an effect on mastectomy skin necrosis.

Methods A single-center study was performed of patients who underwent immediate or delayed DIEP flap reconstruction over a 3-year period. Patients were divided into two groups: Group I (immediate DIEP flap) and Group II (delayed-immediate DIEP with flap staged separately from mastectomy). The outcomes assessed were breast skin flap necrosis and management of skin flap necrosis.

Results The study included 106 patients (173 flaps) in Group I (49 patients, 80 flaps) and Group II (57 patients, 93 flaps). Mastectomy skin flap necrosis rates were 11.3% (9/80) for Group I compared to 2.2% (2/93) of Group II patients (p = 0.025). Skin necrosis necessitating operative debridement was 7.5% (6/80) in Group I and 1.1% (1/93) in Group II (p = 0.0499).

Conclusion Immediate DIEP flaps performed on the day of mastectomy have a significantly higher risk of mastectomy skin necrosis. Patients may be counseled that another advantage of performing a DIEP flap on a different day than a mastectomy is to decrease the risk of mastectomy skin necrosis.

Keywords

deep inferior epigastric perforator - DIEP - mastectomy skin necrosis - free flap


Publication History

Received: 29 October 2024

Accepted: 26 January 2025

Article published online:
11 March 2025

© 2025. Thieme. All rights reserved.

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  • References

  • 1 Allen RJ, Treece P. Deep inferior epigastric perforator flap for breast reconstruction. Ann Plast Surg 1994; 32 (01) 32-38
    CrossrefPubMedSearch in Google Scholar
  • 2 Kelley BP, Ahmed R, Kidwell KM, Kozlow JH, Chung KC, Momoh AO. A systematic review of morbidity associated with autologous breast reconstruction before and after exposure to radiotherapy: are current practices ideal?. Ann Surg Oncol 2014; 21 (05) 1732-1738
    CrossrefPubMedSearch in Google Scholar
  • 3 Damen TH, Timman R, Kunst EH. et al. High satisfaction rates in women after DIEP flap breast reconstruction. J Plast Reconstr Aesthet Surg 2010; 63 (01) 93-100
    CrossrefPubMedSearch in Google Scholar
  • 4 Skraastad BK, Knudsen C, Jackson C, Utheim TP, Pripp AH, Tønseth KA. Quality of life, patient satisfaction and cosmetic outcome after delayed breast reconstruction using DIEP flap: a 10 years' follow-up survey. J Plast Surg Hand Surg 2019; 53 (02) 119-124
    CrossrefPubMedSearch in Google Scholar
  • 5 Pittelkow E, DeBrock W, Christopher L. et al. Advantages of the delayed-immediate microsurgical breast reconstruction: extending the choice. J Reconstr Microsurg 2022; 38 (07) 579-584
    Thieme ConnectPubMedSearch in Google Scholar
  • 6 Kronowitz SJ, Hunt KK, Kuerer HM. et al. Delayed-immediate breast reconstruction. Plast Reconstr Surg 2004; 113 (06) 1617-1628
    CrossrefPubMedSearch in Google Scholar
  • 7 Fertsch S, Munder B, Hagouan M. et al. Immediate-delayed autologous (IDEAL) breast reconstruction with the DIEP flap. Chirurgia (Bucur) 2017; 112 (04) 387-393
    CrossrefPubMedSearch in Google Scholar
  • 8 He S, Yin J, Robb GL. et al. Considering the optimal timing of breast reconstruction with abdominal flaps with adjuvant irradiation in 370 consecutive pedicled transverse rectus abdominis myocutaneous flap and free deep inferior epigastric perforator flap performed in a Chinese oncology center: is there a significant difference between immediate and delayed?. Ann Plast Surg 2017; 78 (06) 633-640
    CrossrefPubMedSearch in Google Scholar
  • 9 Kronowitz SJ. Delayed-immediate breast reconstruction: technical and timing considerations. Plast Reconstr Surg 2010; 125 (02) 463-474
    CrossrefPubMedSearch in Google Scholar
  • 10 Lundberg J, Thorarinsson A, Karlsson P. et al. When is the deep inferior epigastric artery flap indicated for breast reconstruction in patients not treated with radiotherapy?. Ann Plast Surg 2014; 73 (01) 105-113
    CrossrefPubMedSearch in Google Scholar
  • 11 Albino FP, Patel KM, Smith JR, Nahabedian MY. Delayed versus delayed-immediate autologous breast reconstruction: a blinded evaluation of aesthetic outcomes. Arch Plast Surg 2014; 41 (03) 264-270
    Thieme ConnectPubMedSearch in Google Scholar
  • 12 Patel KM, Albino F, Fan KL, Liao E, Nahabedian MY. Microvascular autologous breast reconstruction in the context of radiation therapy: comparing two reconstructive algorithms. Plast Reconstr Surg 2013; 132 (02) 251-257
    CrossrefPubMedSearch in Google Scholar
  • 13 Ter Louw RP, Patel KM, Sosin M, Weissler JM, Nahabedian MY. Patient-centred decision making in breast reconstruction utilising the delayed-immediate algorithm. J Plast Reconstr Aesthet Surg 2014; 67 (04) 477-482
    CrossrefPubMedSearch in Google Scholar
  • 14 O'Connell RL, Di Micco R, Khabra K. et al. Comparison of immediate versus delayed DIEP flap reconstruction in women who require postmastectomy radiotherapy. Plast Reconstr Surg 2018; 142 (03) 594-605
    CrossrefPubMedSearch in Google Scholar
  • 15 Lee TJ, Oh TS, Kim EK. et al. Risk factors of mastectomy skin flap necrosis in immediate breast reconstruction using low abdominal flaps. J Plast Surg Hand Surg 2016; 50 (05) 302-306
    CrossrefPubMedSearch in Google Scholar
  • 16 Matsen CB, Mehrara B, Eaton A. et al. Skin flap necrosis after mastectomy with reconstruction: a prospective study. Ann Surg Oncol 2016; 23 (01) 257-264
    CrossrefPubMedSearch in Google Scholar
  • 17 Lu Wang M, Valenti AB, Thomas G, Huang H, Cohen LE, Otterburn DM. A comparative analysis of risk factors for breast skin necrosis following autologous versus device-based breast reconstruction. J Reconstr Microsurg 2023; 39 (04) 288-294
    Thieme ConnectPubMedSearch in Google Scholar
  • 18 Haddock NT, Teotia SS. Five steps to internal mammary vessel preparation in less than 15 minutes. Plast Reconstr Surg 2017; 140 (05) 884-886
    CrossrefPubMedSearch in Google Scholar
  • 19 Larrabee Jr WF, Holloway Jr GA, Sutton D. Wound tension and blood flow in skin flaps. Ann Otol Rhinol Laryngol 1984; 93 (2 Pt 1): 112-115
    CrossrefPubMedSearch in Google Scholar
  • 20 Davies K, Allan L, Roblin P, Ross D, Farhadi J. Factors affecting post-operative complications following skin sparing mastectomy with immediate breast reconstruction. Breast 2011; 20 (01) 21-25
    CrossrefPubMedSearch in Google Scholar
  • 21 Pinsolle V, Grinfeder C, Mathoulin-Pelissier S, Faucher A. Complications analysis of 266 immediate breast reconstructions. J Plast Reconstr Aesthet Surg 2006; 59 (10) 1017-1024
    CrossrefPubMedSearch in Google Scholar
  • 22 Cordeiro PG, McCarthy CM. A single surgeon's 12-year experience with tissue expander/implant breast reconstruction: part I. A prospective analysis of early complications. Plast Reconstr Surg 2006; 118 (04) 825-831
    CrossrefPubMedSearch in Google Scholar
  • 23 Garwood ER, Moore D, Ewing C. et al. Total skin-sparing mastectomy: complications and local recurrence rates in 2 cohorts of patients. Ann Surg 2009; 249 (01) 26-32
    CrossrefPubMedSearch in Google Scholar
  • 24 Chang DW, Reece GP, Wang B. et al. Effect of smoking on complications in patients undergoing free TRAM flap breast reconstruction. Plast Reconstr Surg 2000; 105 (07) 2374-2380
    CrossrefPubMedSearch in Google Scholar
  • 25 Chang DW, Wang B, Robb GL. et al. Effect of obesity on flap and donor-site complications in free transverse rectus abdominis myocutaneous flap breast reconstruction. Plast Reconstr Surg 2000; 105 (05) 1640-1648
    CrossrefPubMedSearch in Google Scholar
  • 26 McCarthy CM, Mehrara BJ, Riedel E. et al. Predicting complications following expander/implant breast reconstruction: an outcomes analysis based on preoperative clinical risk. Plast Reconstr Surg 2008; 121 (06) 1886-1892
    CrossrefPubMedSearch in Google Scholar
  • 27 Spear SL, Ducic I, Cuoco F, Taylor N. Effect of obesity on flap and donor-site complications in pedicled TRAM flap breast reconstruction. Plast Reconstr Surg 2007; 119 (03) 788-795
    CrossrefPubMedSearch in Google Scholar
  • 28 Singletary SE. Skin-sparing mastectomy with immediate breast reconstruction: the M. D. Anderson Cancer Center experience. Ann Surg Oncol 1996; 3 (04) 411-416
    CrossrefPubMedSearch in Google Scholar
  • 29 Yano K, Hosokawa K, Masuoka T. et al. Options for immediate breast reconstruction following skin-sparing mastectomy. Breast Cancer 2007; 14 (04) 406-413
    CrossrefPubMedSearch in Google Scholar
  • 30 Koesters EC, Chang DW. Radiation and free flaps: what is the optimal timing?. Gland Surg 2023; 12 (08) 1122-1130
    CrossrefPubMedSearch in Google Scholar
  • 31 Rogers NE, Allen RJ. Radiation effects on breast reconstruction with the deep inferior epigastric perforator flap. Plast Reconstr Surg 2002; 109 (06) 1919-1924 , discussion 1925–1926
    CrossrefPubMedSearch in Google Scholar
  • 32 Spear SL, Ducic I, Low M, Cuoco F. The effect of radiation on pedicled TRAM flap breast reconstruction: outcomes and implications. Plast Reconstr Surg 2005; 115 (01) 84-95
    CrossrefPubMedSearch in Google Scholar
  • 33 Moo TA, Nelson JA, Sevilimedu V. et al. Strategies to avoid mastectomy skin-flap necrosis during nipple-sparing mastectomy. Br J Surg 2023; 110 (07) 831-838
    CrossrefPubMedSearch in Google Scholar
  • 34 Yalanis GC, Nag S, Georgek JR. et al. Mastectomy weight and tissue expander volume predict necrosis and increased costs associated with breast reconstruction. Plast Reconstr Surg Glob Open 2015; 3 (07) e450
    CrossrefPubMedSearch in Google Scholar
  • 35 Mulvey CL, Cooney CM, Daily FF. et al. Increased flap weight and decreased perforator number predict fat necrosis in DIEP breast reconstruction. Plast Reconstr Surg Glob Open 2013; 1 (02) 1-7
    CrossrefPubMedSearch in Google Scholar
  • 36 Alves AS, Tan V, Scampa M, Kalbermatten DF, Oranges CM. Complications of immediate versus delayed DIEP reconstruction: a meta-analysis of comparative studies. Cancers (Basel) 2022; 14 (17) 4272
    CrossrefPubMedSearch in Google Scholar
  • 37 Beugels J, Bod L, van Kuijk SMJ. et al. Complications following immediate compared to delayed deep inferior epigastric artery perforator flap breast reconstructions. Breast Cancer Res Treat 2018; 169 (02) 349-357
    CrossrefPubMedSearch in Google Scholar
  • 38 Ochoa O, Garza III R, Pisano S. et al. Prospective longitudinal patient-reported satisfaction and health-related quality of life following diep flap breast reconstruction: effects of reconstruction timing. Plast Reconstr Surg 2022; 149 (05) 848e-857e
    CrossrefPubMedSearch in Google Scholar
  • 39 Prantl L, Moellhoff N, von Fritschen U. et al. Immediate versus secondary DIEP flap breast reconstruction: a multicenter outcome study. Arch Gynecol Obstet 2020; 302 (06) 1451-1459
    CrossrefPubMedSearch in Google Scholar
  • 40 Hart A, Funderburk CD, Chu CK. et al. The impact of diabetes mellitus on wound healing in breast reconstruction. Ann Plast Surg 2017; 78 (03) 260-263
    CrossrefPubMedSearch in Google Scholar
  • 41 Major M, Devulapalli C, Bello RJ. et al. The effect of timing on breast reconstruction outcomes in diabetic women. Plast Reconstr Surg Glob Open 2016; 4 (10) e1090
    CrossrefPubMedSearch in Google Scholar
  • 42 Fischer JP, Tuggle CT, Au A, Kovach SJ. A 30-day risk assessment of mastectomy alone compared to immediate breast reconstruction (IBR). J Plast Surg Hand Surg 2014; 48 (03) 209-215
    CrossrefPubMedSearch in Google Scholar
  • 43 Hassan B, Abou Koura A, Makarem A. et al. Predictors of surgical site infection following reconstructive flap surgery: a multi-institutional analysis of 37,177 patients. Front Surg 2023; 10: 1080143
    CrossrefPubMedSearch in Google Scholar
  • 44 Qin C, Vaca E, Lovecchio F, Ver Halen JP, Hansen NM, Kim JY. Differential impact of non-insulin-dependent diabetes mellitus and insulin-dependent diabetes mellitus on breast reconstruction outcomes. Breast Cancer Res Treat 2014; 146 (02) 429-438
    CrossrefPubMedSearch in Google Scholar
  • 45 Lester ME, Berns J, Dawson S, Newsom K, Hartman B, Hassanein AH. A novel framework for optimizing efficiency and education in microsurgical breast reconstruction. Plast Reconstr Surg Glob Open 2023; 11 (11) e5445
    CrossrefPubMedSearch in Google Scholar
  • 46 Davé N, Hajj JP, Ahmed S. et al. Immediate breast reconstruction for inflammatory breast carcinoma: a scoping review. J Surg Oncol 2024;
    CrossrefPubMedSearch in Google Scholar
  • 47 Rusby JE, Waters RA, Nightingale PG, England DW. Immediate breast reconstruction after mastectomy: what are the long-term prospects?. Ann R Coll Surg Engl 2010; 92 (03) 193-197
    CrossrefPubMedSearch in Google Scholar
  • 48 Ahmed S, Hajj JP, VonDerHaar RJ. et al. Prophylactic absorbable antibiotic beads for prepectoral implant-based breast reconstruction: a single institution early experience. J Plast Reconstr Aesthet Surg 2024; 96: 107-110
    CrossrefPubMedSearch in Google Scholar
  • 49 Ahmed S, Lee JTC, Roth D. et al. Prophylactic absorbable antibiotic beads for high-risk, implant-based prepectoral reconstruction. Plast Reconstr Surg Glob Open 2023; 11 (10) e5353
    CrossrefPubMedSearch in Google Scholar
  • 50 Bamba R, Tran PC, Mailey BA. et al. Comparison of breast reconstruction outcomes using oxychlorosene versus triple antibiotic solution for pocket irrigation. Plast Reconstr Surg Glob Open 2022; 10 (08) e3975
    CrossrefPubMedSearch in Google Scholar
  • 51 Dawson SE, Bamba R, Tran PC. et al. Implant-based breast reconstruction outcomes using oxychlorosene for pocket irrigation. Plast Reconstr Surg 2021; 148 (03) 518e-520e
    CrossrefPubMedSearch in Google Scholar