Advantages Of The Delayed-Immediate Microsurgical Breast Reconstruction: Extending The Choice
Will DeBrock, BS, Eric Pittelkow, MD, Laura Christopher, BS, Raphael Mercho, BS, Brett Hartman, DO, Mary Lester, MD, Aladdin H. Hassanein, MD, MMSc.
Indiana University, Indianapolis, IN, USA.
PURPOSE: Deep inferior epigastric perforator (DIEP) reconstruction can be performed in an immediate, delayed-immediate (immediate tissue expander followed by staged DIEP), or delayed timing following mastectomy. Several advantages of delayed-immediate reconstruction have been previously described which include avoiding radiation of the flap. The interval between the tissue expander placement and DIEP flap may grant patients additional time to choose between autologous and implant reconstruction. The purpose of this study is to evaluate patients undergoing immediate or delayed-immediate DIEP reconstruction.
METHODS: Consecutive patients undergoing breast reconstruction from 2017-2019 by a single surgeon were divided into three groups: immediate DIEP after mastectomy (Group I); delayed-immediate DIEP (Group II); and patients who initially chose delayed-immediate DIEP but later decided on implants for the second stage of reconstruction (Group III). Exclusion criteria were patients that had delayed DIEP (no immediate reconstruction) or had implant reconstruction (direct to implant or two-stage reconstruction with implants as the initial choice). Predictive variables were age, body mass index (BMI), comorbidities, radiotherapy, neoadjuvant or adjuvant chemotherapy, plane of tissue expander (prepectoral or subpectoral) and type of mastectomy. Outcome variables included flap loss, seroma, hematoma, surgical site infection (SSI), wound dehiscence, delayed wound healing, operative times and takeback.
RESULTS: The study included 50 patients: 29 patients in Group I, 11 patients in Group II, and 10 patients in Group III. Unilateral free flaps in Group II had shorter operative times (318 minutes) compared to Group I unilateral free flaps (528 minutes) (p=.02). Average operative time for bilateral flaps was also longer in Group I (550 minutes) compared to Group II (488 minutes) (p=.2). There was no flap loss in Group I or Group II. Nine patients (31%) had prophylactic mastectomies in Group I compared to zero patients in Group II (p=.04). Patients who had immediate tissue expansion as a first stage changed their mind from DIEP to implant for second stage at a rate of 48% (10/21). No difference was found for age (50.7 years Group II versus 46.4 years Group III, p=.4), BMI (31.3 kg/m2 Group II versus 33.8 kg/m2 Group III, p=.3), or radiation (46% Group II versus 40% Group III, p=.9).
CONCLUSION: Delayed-immediate DIEP reconstruction has several advantages over immediate DIEP flap including shorter free flap operative times. Patients changed their preference of second stage reconstruction from autologous to implant 48% of the time after immediate tissue expander placement. A patient-centered advantage of delayed-immediate reconstruction is extending the time window patients have to make their decision regarding their final reconstruction after the malignancy has been treated.
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