Quality of life, patient satisfaction and cosmetic outcome after delayed breast reconstruction using DIEP flap: a 10 years' follow-up survey

Purse-String DIEPplasty: A Technique to Improve Aesthetic Outcome of Autologous Breast Reconstruction

The purse-string DIEPplasty technique is a method to improve aesthetic outcomes in breast reconstruction using deep inferior epigastric perforator (DIEP) free flaps. Traditionally, DIEP flaps, harvested from the lower abdomen, take on a triangular shape that can lead to sub-optimal aesthetic outcomes with occasionally poor breast projection, irregular contours, or minimal upper pole fullness. The purse-string DIEPplasty technique addresses these issues by using a 0 Polydioxanone continuous purse-string suture through the Scarpa's fascia to modify the harvested flap's shape before inset, giving it a more round base and a central dome-like projection similar to an implant. This method mimics the shape of a breast implant, enhancing the flap's projection, volumetric efficiency, and overall shape, leading to a reconstructed breast with improved aesthetic qualities. This technique represents a potential advancement in reconstructive breast surgery, aiming to reduce the extent of revision procedures and improve patient satisfaction. Further research, however, is needed to validate its effectiveness over time and assess potential complications.Level of Evidence IV This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Long-term Donor Site-related Quality of Life after Deep Inferior Epigastric Perforator Flap Breast Reconstruction

Background

Current knowledge about patients' perceptions of the donor site following abdominal-based breast reconstruction and its effect on health-related quality of life (HRQoL) several years after breast reconstruction is limited. This study aimed to assess the long-term effects of deep inferior epigastric perforator (DIEP) flap breast reconstruction on HRQoL, specifically focusing on the abdomen and donor site aspects.

Methods

This retrospective cohort study compared 66 women who underwent DIEP breast reconstruction between 2000 and 2007 with a matched control cohort of 114 women who underwent therapeutic mastectomies without reconstruction in the year 2005. The DIEP cohort of patients completed the BREAST-Q Reconstruction module during an outpatient visit in 2015-2016. The control cohort completed the same questionnaire online in 2016.

Results

The follow-up time was at least 8 years (mean 11.4 ± 1.6 years) postreconstruction for the DIEP cohort and 10 years postmastectomy (mean 11.0 ± 0.3 years) for the control cohort. In the DIEP cohort, 93% reported no donor site pain, 89% had no difficulty sitting up, and 91% had no activity limitations 2 weeks before completing the survey. Patients undergoing DIEP were more satisfied with their abdominal appearance than the control group (adjusted OR, 5.7; 95% confidence interval 1.8-17.6).

Conclusions

A decade postoperatively, DIEP breast reconstruction yields high abdominal donor site satisfaction, with comparable abdominal physical well-being to nonreconstructed women.

Outcomes of Deep Inferior Epigastric Artery Perforator (DIEP) Flap in Indian Population-A Prospective Single-Institute Study

Introduction  Breast reconstruction has become integral part of breast cancer treatment. Deep inferior epigastric perforator (DIEP)-based flap is considered the gold standard in autologous breast reconstruction. Aims and Objectives  The aim of this study was to evaluate the patient satisfaction and the incidence of complications in DIEP flaps in an Indian setup for breast reconstruction. Materials and Methods  This is a prospective, nonrandomized study at a single institute-Manipal Hospitals, Old Airport Road, Bangalore. Eligible patients were women aged between 28 and 60 years with primary breast cancer requiring mastectomy and radiotherapy, who consented for DIEP flap reconstruction. Results  The study includes subjects who had autologous breast reconstruction after mastectomy with DIEP flap between January 2019 and August 2021 that included 31 patients with a minimum follow-up of 2 years. Four flaps were turbocharged and 17 flaps were superdrained primarily. The average operative time for the whole procedure by adopting a two-team approach is 353.8 ± 43.793 minutes. About 94.1% patients had excellent aesthetic score results. Six patients developed mastectomy flap necrosis, one had fat necrosis that was managed conservatively, whereas one patient had donor site re-exploration for hematoma. We had no DIEP flap necrosis, seroma, flap site hematoma, or flap failure. Physical well-being module of Breast-Q indicated an average of 83 points, psychosocial well-being module indicated 80 points, whereas sexual scores reverted an average of 77 points. Among satisfaction module, aesthetic outcomes for breast showed an average of 94 points, whereas the donor site had 96 points. Satisfaction with information, surgeon, medical staff each gained more than 87 points. Conclusion  Breast reconstruction with DIEP flap yields good aesthetic outcomes and quality of life in Indian population. The incidence of fat necrosis, flap and donor site complications is less over time and will enhance the patient satisfaction score further.

Perforator Characteristics and Impact on Postoperative Outcomes in DIEP Flap Breast Reconstruction: A Systematic Review and Meta-Analysis

BACKGROUND

 High-quality evidence on perforator selection in deep inferior epigastric perforator (DIEP) flap harvesting is lacking, making preoperative planning and choice of perforators "surgeon-specific." This lack of consensus is a subject of continuous debate among microsurgeons. We aimed to systematically review perforator characteristics and their impact on DIEP flap breast reconstruction outcomes.

METHODS

 We conducted a systematic review and meta-analysis across six databases: ClinicalTrials.gov, Cochrane Library, Medline, Ovid Embase, PubMed, and Web of Science for all studies on DIEP flap breast reconstruction focused on perforator characteristics-caliber, number, and location. The primary goal was to analyze the impact of perforator characteristics on partial and/or total flap failure and fat necrosis. Data was analyzed using RevMan V5.3.

RESULTS

 Initial search gave us 2,768 articles of which 17 were included in our review. Pooled analysis did not show any statistically significant correlations between partial and/or total flap failure and perforator number, or perforator location. Sensitivity analysis accounting for heterogeneity across studies showed that, the risk for fat necrosis was significantly higher if single perforators (relative risk [RR] = 2.0, 95% confidence interval [CI] = 1.5-2.6, I ² = 39%) and medial row perforators (RR = 2.7, 95% CI = 1.8-3.9, I ² = 0%) were used.

CONCLUSION

 Our findings suggest that a single dominant perforator and medial row perforators may be associated with higher risk of fat necrosis after DIEP flap breast reconstruction. Adopting a standardized perforator selection algorithm may facilitate operative decision making, shorten the learning curve for novice surgeons, and optimize postoperative outcomes by minimizing the burden of major complications. This in turn would help improve patient satisfaction and quality of life.

Prospective Longitudinal Patient-Reported Satisfaction and Health-Related Quality of Life following DIEP Flap Breast Reconstruction: Effects of Reconstruction Timing

BACKGROUND

Without reconstruction, mastectomy alone can produce significant detrimental effects on health-related quality of life. The magnitude of quality-of-life benefits following breast reconstruction may be unique based on timing of reconstruction. Facilitated by the BREAST-Q questionnaire, characterization of how reconstruction timing differentially affects patient-reported quality of life is essential for improved evidence-based clinical practice.

METHODS

Consecutive DIEP flap breast reconstruction patients prospectively completed BREAST-Q questionnaires preoperatively and at two different time intervals postoperatively. The first (postoperative time point A) and second (postoperative time point B) postoperative questionnaires were completed 1 month postoperatively and following breast revision/symmetry procedures, respectively. Postoperative flap and donor-site complications were recorded prospectively. Stratified by timing (immediate versus delayed) of reconstruction, preoperative clinical data, operative morbidity, and BREAST-Q scores were compared at all time points.

RESULTS

Between July of 2012 and August of 2016, 73 patients underwent 130 DIEP flap breast reconstructions. Collectively, breast satisfaction, psychosocial well-being, and sexual well-being scores significantly (p < 0.001) increased postoperatively versus baseline. Chest and abdominal physical well-being scores returned to baseline levels by postoperative time point B. Preoperatively, patients undergoing delayed breast reconstruction reported significantly (p < 0.05) lower breast satisfaction, psychosocial well-being, and sexual well-being scores compared to immediate reconstruction patients. Postoperatively, delayed and immediate reconstruction patients reported similar quality-of-life scores. Outcome satisfaction and flap and donor-site morbidity were similar between groups irrespective of timing of reconstruction.

CONCLUSIONS

In this prospective study, patient-reported outcomes demonstrate significant improvements in breast satisfaction, psychosocial well-being, and sexual well-being among patients following DIEP flap reconstruction. Moreover, preoperative differences in quality-of-life scores among delayed/immediate reconstruction patients were eliminated postoperatively.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, II.

Patient-reported outcomes following bilateral prophylactic mastectomy and immediate breast reconstruction: comparing implant-based with autologous breast reconstruction

Background

Since the number of breast cancer genetic gene testing is increasing, more women opt for bilateral prophylactic mastectomy (BPM) followed by breast reconstruction. However, little is known about the differences in Quality of Life (QoL) after various reconstructive surgeries in this population. In this study, the long-term breast-related, body-related, and health-related QoL between immediate implant-based breast reconstruction (IBBR) and autologous breast reconstruction (ABR) were compared, in women who underwent BPM.

Methods

In this cross-sectional study, women who underwent postmastectomy breast reconstruction between January 2015 and December 2018 were invited for an online questionnaire, in which the BREAST-Q, the BODY-Q and the SF-36 were included. Women who underwent BPM and immediate breast reconstruction were included for analysis. Multivariable linear regression analysis was performed to adjust mean differences in patient-reported outcomes between IBBR and ABR for potential confounders.

Results

Of the included women (n = 47), 33 underwent ABR and 14 women underwent IBBR following BPM. BREAST-Q scores were in favor of the ABR group before and after adjustment, with statistically significance on Satisfaction with breasts (mean difference 15.8, p = 0.019) and Physical well-being (mean difference 13.5, p = 0.033). None of the mean differences in BODY-Q and SF-36 scores between groups, before and after adjustment, were statistically significant.

Conclusion

This study suggests that there is a higher satisfaction with breasts and better physical well-being in women who underwent immediate ABR compared to those who underwent immediate IBBR after BPM. However, these data should be interpreted carefully as a result of selection bias and a small sample size.

Level of Evidence: Level III, risk study.

The difference in local, regional and distant breast cancer recurrence between the immediate and delayed DIEP flap procedure; a retrospective cohort study

Purpose

It has been hypothesized that autologous breast reconstruction can cause reactivation of dormant micro metastases by its extensive tissue trauma, influencing the risk of breast cancer recurrence. However, about the specific effect of timing on breast cancer recurrence in the deep inferior epigastric perforator (DIEP) flap reconstruction is not much known. In this study the rate of local, regional and distant recurrence between patients undergoing an immediate and delayed autologous DIEP flap breast reconstruction were evaluated.

Methods

In this retrospective cohort study, breast cancer patients undergoing a DIEP flap breast reconstruction between 2010 and 2018 in three hospitals in the Netherlands were evaluated. Cox proportional hazards regression analyses were performed to assess the impact of different factors on breast cancer recurrence. The primary endpoint was local breast cancer recurrence. Secondary endpoints were regional and distant recurrence.

Results

A total of 919 DIEP-flap reconstructions were done in 862 women of which 347 were immediate- and 572 were delayed DIEP flap reconstructions. After a median follow-up of 46 months and 86 months respectively (p < 0.001), local breast cancer recurrence occurred in 1.5% and in 1.7% of the patients resulting in an adjusted hazard ratio of 2.890 (p = 0.001, 95% CI 1.536, 5437).

Conclusion

This study suggests an increased risk for breast cancer recurrence in women receiving a delayed DIEP flap reconstruction as compared to women receiving an immediate DIEP flap reconstruction. However, these data should be interpreted carefully as a result of selection bias.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10549-021-06199-3.