ONE-STAGE DIEP FLAP BREAST RECONSTRUCTION: ALGORITHM FOR IMMEDIATE CONTRALATERAL SYMMETRIZATION ROSARIA LAPORTA, M.D., BENEDETTO LONGO, M.D., Ph.D., MICHAIL SOROTOS, M.D., MARCO PAGNONI, M.D., and FABIO SANTANELLI DI POMPEO, M.D., Ph.D.*
The aim of this study was to investigate clinical and aesthetic results of simultaneous contralateral balancing procedures in unilateral DIEP flap reconstructions by means of a symmetrization algorithm. Between 2004 and 2013, 335 patients underwent DIEP flap breast reconstruction with 48 patients (mean age 51.8 years, range 32–69 years) undergoing contralateral procedure. Patients were divided in Group-A including 31 cases who underwent one-stage procedure and Group-B including 17 cases who underwent staged procedure. A symmetrization algorithm was proposed to plan immediate breast reduction/mastopexy. The groups were homogeneous regarding patient’s age, BMI, mastectomy and flap weight (P > 0.05). All flaps survived. No complications were observed to the mastectomy skin flaps and to the reduction mammaplasty/mastopexy procedures in both groups. The mean operation time was 5 h in Group-A while 5 h and 37 min in Group-B (P 5 0.0682). Contralateral procedures included 23 breast reductions and 8 mastopexies in Group-A, while 10 breast reductions and 7 mastopexies were performed in Group-B. Two and 6 patients required revision of the balancing procedure in Group-A and Group-B, respectively. The follow-up time was 47.3 months (range 14–120 months) in Group-A and 91.3 months (range 41– 110 months) in Group-B. Volume, upper/lower pole shape, projection, breast mound placement, IMF, symmetry, overall appearance, and general satisfaction sub-items obtained high-score evaluation without significant difference between the two groups (P > 0.05). One-stage DIEP flap reconstruction by means of the symmetrization algorithm resulted in comparable aesthetic outcomes and patient satisfaction to C 2015 Wiley Periodicals, Inc. Microsurgery 36:7–19, 2016. a staged procedure. V
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definition of a satisfactory outcome is not only survival through total eradication of breast cancer but also a symmetrical and aesthetically pleasing breast reconstruction. This often requires additional balancing procedures to the contralateral side in the form of augmentation, reduction, or mastopexy.1–3 The decision to carry on with either an immediate or a staged procedure is often subjective in both implant and autologous reconstruction. Advocates of the simultaneous technique describe the advantages of using the revised contralateral breast as a “footprint” for the reconstructed breast to achieve symmetry in one-stage, decreasing patient morbidity, reoperation time, improving patients’ quality of life and reducing costs in an already overburdened health-care system.4,5 Conversely, some surgeons prefer to perform a staged procedure because of the potential disadvantages of a one-stage procedure such as longer operating times, blood loss, difficulty in achieving pleasant long-term symmetry, and eventual modification by adjuvant radiotherapy.6,7 In literature, no reports focus attention on the need of an algorithm to plan breast symmetrization in different types of clinical conditions to optimize shape, volume, and projection symmetry avoiding secondary revision surgery if one-stage reconstruction is scheduled. The objectives of this study were Plastic Surgery Department, Sant’andrea Hospital, School of Medicine and Psychology, “Sapienza” University of Rome, Rome, Italy *Correspondence to: Fabio Santanelli di Pompeo, M.D., Ph.D., Via di Grottarossa 1035-1039, 00189 Rome, Italy. E-mail: [email protected] Received 30 September 2014; Revision accepted 18 January 2015; Accepted 13 February 2015 Published online 2 March 2015 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/micr.22390 Ó 2015 Wiley Periodicals, Inc.
to investigate the clinical and aesthetic outcomes of one-stage deep inferior epigastric perforator (DIEP) flap breast reconstruction by means of a symmetrization algorithm. PATIENTS AND METHODS
A retrospective review was performed of patients undergoing DIEP flap transfer after mastectomy, from May 2004 to September 2013, by the senior surgeon (FSdP) at a single cancer center. A total of 335 women had reconstruction following mastectomy among which 16 (4.8%) were bilateral and 319 (95.3%) unilateral. All patients received preoperative Computerized-Tomography Angiography to evaluate the flap perforators’ pattern, which, as other studies confirm, proved helpful in identifying the ideal perforator.8 However, we did not perform any radiologic study for the recipient vessels. Inclusion criteria were unilateral reconstruction with contralateral mastopexy/reduction procedure and followup at least 1 year after primary surgery. Scar revisions and minor revisions performed under local anesthesia were not evaluated. Six different clinical situations were identified and for each of them a preoperative planning was developed to reach symmetry in one-stage procedure, and classified according to incision pattern. In all cases, the median breast line was marked and then the new nipples were positioned along it 23 cm from the sternal notch. Planning type-1 (Wise-pattern, WP): when skinsparing mastectomy (SSM) type IV was indicated on affected breast because of the tumor located in the lower pole,9 WP incisions were marked bilaterally. New
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Figure 1. Planning type-1 (WP). The median breast line was marked, the new nipples were positioned along it approximately at 23 cm from the sternal notch. WP incisions were marked bilaterally. New NAC was measured 5 cm (A); the lateral arms of the pattern were measured 6–8 cm (B) and the distance between them was 5–7 cm (C). DIEP flap markings with round skin paddle and the deepithelialized area (pink color) of the flap (D).
Figure 2. A 46-year-old woman with previous left breast periareolar lumpectomy scar underwent immediate one-stage reconstruction following left SSM-IV. Preoperative and postoperative frontal view.
nipple-areola complex (NAC) was measured 5 cm with a radius of 2.5 cm; the lateral arms of the pattern were measured 6–8 cm rather than 5 cm while the distance between them was 5–7 cm rather than 9 cm (Figs. 1 and 2). Planning type-2 (Inverted WP): in case of vertical scar incision from previous lumpectomy/quadrantectomy Microsurgery DOI 10.1002/micr
located in the upper pole, the “inverted WP” was drawn turning of 180 the pattern on the affected breast, while “standard” pattern was marked on the contralateral side. Same principles regarding WP measurements were applied to both sides. The vertical scar was included in the upper pole skin resection area matching the contralateral (reduction/mastopexy) resection area. To position
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Figure 3. Planning type-2 (Inverted WP). The “ inverted WP” was drawn turning of 180 the pattern on the affected breast, while “ standard” pattern was marked on the contralateral side. The vertical scar was included in the upper pole skin resection area (i.e., B 5 10 cm in height) matching the contralateral (reduction/mastopexy) resection area (i.e., A 5 10 cm in height). NAC on the affected breast was located at 33 cm from the sternal notch (23 cm 1 B). DIEP flap markings with a round skin paddle and the de-epithelialized area (pink color) of the flap (C).
Figure 4. A 56-year-old woman, with previous vertical right breast quadrantectomy in the upper pole underwent immediate one-stage reconstruction following “ inverted WP.” Preoperative and postoperative frontal view.
NAC at 23 cm from the sternal notch on the affected breast, the distance was calculated taking into account the area of skin resection from the upper pole; if the latter was 10 cm in height, NAC was located at 33 cm from the sternal notch (Figs. 3 and 4). Planning type-3 (Double-mirrored omega pattern, DMOP): in case of horizontally oriented scar incision
in the medial/lateral upper pole from previous lumpectomy/quadrantectomy in irradiated/smoker patient or in a smoker patient without previous surgery, a DMOP was applied on the affected breast. NAC was located at 23 cm from sternal notch on both breasts. Centering on this point, the upper areola semicircle was drawn with a radius of 2.5 cm on the affected Microsurgery DOI 10.1002/micr
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Figure 5. Planning type-3 (DMOP). NAC position was located at 23 cm from sternal notch on both breasts. Centering on this point, the upper areola semicircle was drawn while the lower areola semicircle is marked at the distance to IMF (A) equal to the length of the lateral arms of contralateral WP (B). On the unaffected breast “ standard” WP was applied. DIEP flap markings with a round skin paddle and the de-epithelialized area (pink color) of the flap (C).
Figure 6. A 52-year-old-smoker woman underwent immediate one-stage reconstruction following DMOP. Preoperative and postoperative frontal view.
side, while the lower areola semicircle was marked at the distance to inframammary fold (IMF) equal to the length of the lateral arms of contralateral WP. Finally, both ends of the two semicircles were connected to the medial and lateral borders of the breast. On the unaffected breast, “standard” WP was applied (Figs. 5 and 6). Microsurgery DOI 10.1002/micr
Planning type-4 (SSM-V): in case of horizontally oriented scar incision in the medial/lateral upper pole from previous lumpectomy/quadrantectomy in nonirradiated/ nonsmoker patient or if the tumor was superficially located in the medial/lateral upper pole, a “modified WP” for upper quadrant skin resection (SSM-V) was applied.10 “Standard WP” was used to perform
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Figure 7. Planning type-4 (SSM-V). “ Modified WP” for upper quadrant skin resection (SSM-V) was applied. “ Standard WP” was used to perform mastopexy/reduction on the opposite breast. Same principles regarding WP measurements were applied. DIEP flap markings with a round skin paddle and the de-epithelialized area (pink color) of the flap (D).
Figure 8. A 55-year-old woman, with previous horizontally oriented quadrantectomy scar in the lateral upper pole, underwent immediate one-stage reconstruction following SSM-V. Preoperative and postoperative frontal view.
mastopexy/reduction on the opposite breast (Figs. 7 and 8). Same principles regarding WP measurements were applied. Planning type-5 (MRM-Immediate reconstruction): if modified radical mastectomy (MRM) was to be performed, height (MRM-H) and width (MRM-W) of the planned
elliptical excision were recorded. Then, WP was applied on the unaffected breast with NAC at 23 cm from sternal notch and vertical branches of 6–8 cm in length according to the desired final volume (Figs. 9 and 10). MRM-H minus the height of lower pole skin reduction on the contralateral breast was equal to the length of the minor axis Microsurgery DOI 10.1002/micr
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Figure 9. Planning type-5 (MRM-Immediate reconstruction). Height (MRM-H) and width (MRM-W) of the planned elliptical excision are recorded. WP was applied on the unaffected breast. MRM-H minus the height of lower pole skin reduction on the contralateral breast (A) was equal to the length of the minor axis of the DIEP flap skin paddle (C), while MRM-W minus the distance between the vertical WP branches (B) was the length of the major axis (D). The subcutaneous defect on the upper portion of mastectomy side was restored including to the DIEP flap skin ellipse the available deepithelialized abdominal tissue (D).
Figure 10. A 54-year-old woman underwent immediate one-stage reconstruction following left MRM. Preoperative and postoperative frontal view.
of the DIEP flap skin paddle, while MRM-W minus the distance between the vertical WP branches (on the unaffected breast) was the length of the major axis. Planning type-6 (MRM-Delayed reconstruction): WP was applied on the unaffected breast with NAC at 23 cm from sternal notch and with the vertical branches 6–8 cm in length according to desired final volume. The IMF was marked on the unaffected side, and a line symmetrical (a) Microsurgery DOI 10.1002/micr
to it was drawn on the mastectomy side. From the sternal notch to new IMF, passing through the new nipple position, a line (b) was drawn on the unaffected breast; a similar line (c) was drawn on the mastectomy side reaching line a. Lines b and c were measured: the difference between them and the amount of scar tissue resection (line d) provided the skin deficit on the affected side and the length of the minor axis of the DIEP flap skin paddle. Because of the
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Figure 11. Planning type-6 (MRM-Delayed reconstruction).WP was applied on the unaffected breast. Line a symmetrical to IMF on the unaffected was marked on the mastectomy side. From the sternal notch to new IMF, passing through the new nipple position, line b was drawn on the unaffected breast; line c was drawn on the mastectomy side reaching line a. b 2 c 1 d 1 (2–4 cm) 5 the length of the minor axis of the DIEP flap skin paddle (D). The breast equator (AB) minus the distance between the two vertical WP branches (C) 5 the length of the major axis of the DIEP flap skin paddle (E). The subcutaneous defect on the upper portion of mastectomy side was restored including to the DIEP flap skin ellipse the available de-epithelialized abdominal tissue (F).
Figure 12. A 44-year-old woman underwent delayed DIEP flap reconstruction and contralateral breast procedure following right MRM. Preoperative and postoperative frontal view.
degree of skin tension from the previous mastectomy, 2– 4 cm was added to this difference (lines b 2 c 1 d). The breast equator (from point A to B) minus the distance between the two vertical WP branches on the unaffected
breast was the length of the major axis of the DIEP flap skin paddle (Figs. 11 and 12). The subcutaneous defect on the upper portion of mastectomy side was restored including to the DIEP flap Microsurgery DOI 10.1002/micr
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Figure 13. Breast symmetrization algorithm. MRM: modified radical mastectomy; SSM-V: skin sparing mastectomy type V.
skin ellipse the available deepithelialized abdominal tissue (C). In all cases described, the volume resection of the unaffected breast and the flap weight was established according to the mastectomy weight. This means that if the latter was 1000 g, the contralateral breast might have been reduced of 300 g, while flap weight of 700 g was required to perform reconstruction. Lumpectomy/quadrantectomy weight, if previously performed, was added to desired breast reduction weight. Breast symmetrization algorithm was summarized in Figure 13. Patients were divided in Group-A including those who underwent contralateral symmetry procedure in onestage and Group-B including those who underwent a staged procedure. Aesthetic and non-aesthetic complications were evaluated. The aesthetic complications included: malposition, volume deficiency/excess of the reconstructed breast and contralateral breast revision. The nonaesthetic complications included mastectomy flap necrosis, partial/total flap loss, venous thrombosis, arterial thrombosis, and donor site complications. Demographic data (age, BMI), reconstruction timing, mastectomy and flap weight, volume of breast tissue removed on the contralateral side, hospital stay, type of symmetry procedure, number of take-backs to the theater for secondary procedures were also entered. Aesthetic analysis was also done by pre and postoperative digital photographs to grade aesthetic results, at least 12 months follow-up, by patients and blinded plastic surgeons (2 independent observers) who were uninvolved in these reconstructive series. The grading scale applied was a modification of that original described by Microsurgery DOI 10.1002/micr
Cohen et al.11 Volume, upper pole and lower pole shape, projection, placement of the breast mound on the chest wall, IMF, symmetry, overall appearance, and general satisfaction were scored ranging from 1 to 5 (Table 1). Inter-rater reliability was calculated for each of the picture grading subscales using the Cohen’s Kappa.12 The strength of agreement was classified based on the Œ score as follows: less than 0.00, poor; 0.00 to 0.20, slight; 0.21 to 0.40, fair; 0.41 to 0.60, moderate; 0.61 to 0.80, substantial; and 0.81 to 1.00, almost perfect agreement.13 Continuous and categorical variables were analyzed using student t test and Kruskal-Wallis test, respectively. A value of P 0.05 was considered statistically significant. RESULTS Clinical Outcomes
The two groups were homogeneous regarding patient’s age, BMI, mastectomy and flap weight (P > 0.05) (Table 2). Group-A included 31 patients, 27 had immediate reconstruction, of which 17 following SSM and 10 following MRM, while 4 patients had delayed reconstruction. Planning type-1 was performed in 7 patients, type-2 in 3 patients, type-3 in 6 patients, type 4-6 in 5 patients for each. Group-B included 17 patients of which 8 had immediate reconstruction and 9 delayed one following MRM in all cases. Twenty-two flaps were anastomosed to circumflex scapular vessels (CSV), 6 to thoracodorsal vessels (TDV), and 3 to internal mammary vessels (IMV) in Group-A, while 4 flaps were anastomosed to CSV, 6 to TDV, and 7 to IMV in Group-B.
Volume, upper pole and lower pole shape, breast’s projection, placement of the breast mound, IMF, symmetry, overall appearance, and general satisfaction were scored ranging from 1 to 5.
Unacceptable Unacceptable Very dissatisfied Good Good Satisfied Very good Very good High
Placement of the breast mound on the chest wall (vertical position) Placement of the breast mound on the chest wall (horizontal position) IMF
Upper pole shape Lower pole shape Breast’s projection
Symmetry Overall appearance General satisfaction
A perfectly naturalappearing, continuous fold with a gentle, smooth curve Excellent Excellent Very high
Poor Poor Dissatisfied
Undetectable IMF Discontinuous fold but gentle, smooth curve A natural-appearing, continuous fold with a gentle, smooth curve
Extremely far laterally
Discontinuous fold and irregular curve
Moderately far medially Moderately far laterally
Very good resemblance Very good resemblance Very good: very youthful appearing breast Extremely far superiorly
Perfectly/normally/ideally Extremely far medially
Very Mild discrepancy relative to contralateral side Very poor resemblance Very poor resemblance Very poor: very aged appearing breast Moderately far superiorly Marked discrepancy relative to contralateral side Poor resemblance Poor resemblance Poor: aged appearing breast Extremely far inferiorly Mild discrepancy relative to contralateral side Good resemblance Fair resemblance Good resemblance Fair resemblance Good: youthful appearing Fair breast Moderately far inferiorly Perfectly/normally/ideally Symmetrical Very symmetrical Volume
Score 3 Score 2 Score 1 Subitems
Table 1. Subscale Analysis of Breast Reconstruction
Score 4
Score 5
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The choice of adopting one-stage procedure instead of the staged one changed during the years; Group-A were patients in the later part of the time period reviewed while Group-B was in the earlier part. Patients were discharged on mean 5.6th postoperative day (range 5–7 days) in Group-A and on 5.5th day (range 5–8 days) in Group-B with no statistical difference (P 5 0.601). All flaps completely survived but one in Group-A (type-5) developed a venous congestion leading to a partial necrosis of zone III, which was debrided on day 10 without further procedure to optimize symmetry. No complications were observed to the mastectomy skin flaps and to the reduction mammaplasty/mastopexy procedures with regards to skin necrosis, nipple areolar partial/total loss, hematoma, and fat necrosis in both groups. Mean operation time was 5 hours (range, 3 hours and 50 minutes to 6 hours) in Group-A while 5 hours and 37 minutes (range, 5 hours to 6 hours and 25 minutes) in Group-B, which was not statistically significant (P 5 0.0682). In Group-A 23 breast reductions and 8 mastopexies were performed with a mean reduction weight of 168 gr (range 100–350) while in Group-B were performed 10 breast reductions and 7 mastopexies with a mean reduction weight of 147 gr (range 100– 230). The average time between primary surgery and contralateral procedure was 10.80 months (range 5–36 months) in Group-B. The range of secondary procedures and their incidence in both groups are shown in Table 3. Mean number of take-back was not calculated because only two patients required revision of the contralateral balancing procedure in Group-A. Conversely, at a mean follow-up of 27 months (range, 24–36 months), in Group-B 2 patients required additional revision of the reconstructed breast by liposuction, 4 of the previous reduction mammaplasty, while 2 cases of the mastopexy. Revision of the reconstructed breast and of the previous mastopexy/breast reduction was considered aesthetic complications. No patients experienced postoperative radiation therapy. The follow-up time from primary oncological surgery to aesthetic evaluation was 47.30 months (range 14– 120 months) in Group-A and 91.30 months (range, 41– 110 months) in Group-B. None of the reduced breast tissue revealed breast cancer in the final histological examination. Aesthetic Results
Volume, upper pole and lower pole shape, breast’ projection, placement of the breast mound, IMF, symmetry, overall appearance and general satisfaction subitems got high score evaluation without significant difference between survey results from Group-A and Group-B patients and surgeons (P > 0.05) (Tables 4 and 5). InterMicrosurgery DOI 10.1002/micr
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Laporta et al. Table 2. Patients’ Data and P Values from the Continuous Variables Mean patient’age (years)
Mean BMI (kg/m2)
Mean mastectomy Weight (gr)
Mean flap weight (gr)
52.2 (range 32–69) 51.3 (range 33–63) 0.164
27.7 (range 25–31) 27.6 (range 24–30) 0.840
753 (range 500–1150) 722 (range 550–980) 0.893
615 (range 500–800) 632 (range 500–850) 0.552
Group-A Group -B P-value BMI: body max index.
Table 3. Range of Procedures and Their Incidence in Group-A and Group-B Group-A
Group-B Planned procedure Additional unplanned procedure
Secondary procedures Lipofilling of the reconstructed breast Liposuction of the reconstructed breast Mastopexy Reduction mammaplasty Revision of mastopexy Revision of reduction mammaplasty
rater agreement between surgeon observers was substantial for all subitems while it was moderate-substantial between surgeon and patient evaluations. DISCUSSION
Although good, consistent result is sometimes possible with a unilateral DIEP flap reconstruction, contralateral procedures are often required to achieve symmetric breast mounds. Few articles are published on this topic, especially concerning how to plan simultaneous procedures in a single stage. Stevenson and Goldstein compared TRAM flap and immediate contralateral breast reduction/mastopexy with TRAM flap alone; their results suggested that performing the combined procedure was safe and yielded a satisfactory aesthetic result.2 Losken et al. presented a series of 1394 patients, but they did not compare outcomes between simultaneous and staged procedures.1 Hakyal and Guay reported a single-stage autologous reconstruction by the use of pedicled flaps (25.8%) and free flaps (75.2%) with 11.3% of postoperative aesthetic complications in 141 patients, the most common being volume excess (5.7%) followed by malposition (2.1%), volume loss due to weight loss (1.4%), asymmetry of shape (1.4%), and volume deficiency (0.7%).14 Huang et al. also performed a study focusing on DIEP and superficial inferior epigastric artery flaps comparing clinical and aesthetic outcomes in immediate and staged contralateral surgery. They claimed greater patient satisfaction, minimal increase in operative time, and no increase in complication rates.15 Free tissue transfer using DIEP flap is considered by many to be the preferred choice for autologous Microsurgery DOI 10.1002/micr
n (%)
n (%)
2 2 2 2 2 2/31 (6.5%)
7/17 (41.2%) 6/17 (35.3%) 2/17 (11.8%) 7/17 (41.2%) 10/17 (58.8%) 2/20 (11.8%) 4/20 (24.5%)
reconstruction,16220 having higher short- and long-term patient satisfaction, along with improved psychosocial and sexual well being.21,22 Extra time is often needed in flap harvest because of the intramuscular perforator’s course and contralateral procedure can discourage surgeons due to the theoretical increase in operating time. Furthermore partial or complete flap failure or radiotherapy damage may result in additional take-backs to the theater and troubles performing revision on the reconstructed breast and on already reduced contralateral side in attempt to preserve symmetry. No statistical difference was found between groups regarding mean operative time and patients discharge. In our practice, DIEP flap harvest, mastectomy procedure, and recipient vessels dissection were routinely performed simultaneously. The flap was transferred, rotated 180 and fixed temporarily to the chest wall; both arterial and venous anastomoses were performed while donor site closure was carried out by a second team. Next, the senior surgeon completed flap insetting while the senior assistant performed the contralateral procedure. The recipient vessels selection changed during the year showing an inversion of the trend between TDV and CSV and a continuous decrease of the IMV. We believe that CSV can be safely used as recipient vessels both for immediate and delayed reconstructions due to easier dissection compared to the one for the IMV because of their anatomical characteristics; greater and more constant caliber than the IMV perforator vessels; optimal flap insetting due to the pedicle’s length when dissected until its origin as previously described.23 Moreover, their location in the posterior axillary region does not expose them completely to the consequences of radiotherapy.24,25 Finally,
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Table 4. Patient Survey Results Mean Score
Volume Upper pole shape Lower pole shape Breast’s projection Placement of the breast mound on the chest wall (vertical position) Placement of the breast mound on the chest wall (horizontal position) IMF Symmetry Overall appearance General satisfaction
Group-A
Group-B
P
1.68 6 0.702 1.52 6 0.626 1.55 6 0.723 1.48 6 0.570 2.77 6 0.425
1.76 6 0.752 1.47 6 0.514 1.47 6 0.717 1.59 6 0.507 2.71 6 0.470
0.707 0.941 0.683 0.545 0.605
2.77 6 0.425
2.76 6 0.437
0.941
1.45 6 0.568 1.97 6 0.795 1.71 6 0.693 1.90 6 0.790
1.41 6 0.507 1.82 6 0.636 1.76 6 0.562 2.29 6 0.470
0.890 0.554 0.665 0.076
Group-A
Group-B
P
1.58 6 0.672 1.36 6 0.55 1.47 6 0.59 1.42 6 0.50 2.56 6 0.51
1.73 6 0.62 1.47 6 0.61 1.44 6 0.56 1.50 6 0.51 2.62 6 0.50
0.380 0.526 0.916 0.602 0.724
2.53 6 0.50
2.71 6 0.47
0.249
1.48 6 0.57 1.71 6 0.69 1.65 6 0.61
1.35 6 0.493 1.91 6 0.68 1.56 6 0.60
0.467 0.318 0.565
Table 5. Surgeon Survey Results Mean Score
Volume Upper pole shape Lower pole shape Breast’s projection Placement of the breast mound on the chest wall (vertical position) Placement of the breast mound on the chest wall (horizontal position) IMF Symmetry Overall appearance
their use does not influence the choice of alternative flaps such as latissimus dorsi flap. Operative time related to vessels selection was not assessed because it was not the aim of the current study. The choice of adopting one-stage procedure instead of the staged one changed from 2004 to date, since our approach regarding the preoperative planning for DIEP flap breast reconstructions changed as well. In the early experience of the senior surgeon, the choice of a onestage over a staged procedure was guided by the severity of breast hypertrophy, in order not to produce significant residual asymmetry following primary surgery. Moreover, formerly the longer operative time to harvest a DIEP flap was discouraging to perform an additional procedure simultaneously. Currently, all patients are considered eligible candidates to undergo a symmetrization procedure, unless they refuse surgery on the unaffected breast. From our experience seemed that mean operative time, clinical and aesthetic complication rate in DIEP flap reconstruction may be mostly related to surgeon experience and skills rather than multiple procedures in one-stage. Conversely, if multiple procedures are performed in more sessions by
different plastic surgeons, the incidence of take-backs for revision surgery could increase. In Group-A, only two patients required take-back to the theater while in GroupB all patients underwent secondary delayed procedures (reduction/mastopexy) and further 8 patients required additional revision surgery. We evaluated the number of take-backs to the theater rather than each procedure because multiple procedures can be performed simultaneously in only one session. The average time between breast reconstruction and contralateral surgery in Group-B was 10.80 months (range 5–36 months.). At our institution breast symmetrization was always offered to the patients within 6 months after primary surgery but some of them wished to delay it. Delayed take-backs to theater were probably influenced by negative patient cancer experience, extending the time to complete the reconstruction. In one-stage procedure, the main issue is how to plan DIEP flap reconstruction simultaneously to a conventional breast reduction/mastopexy. The ideal distances from the sternal notch to the nipple and from the mid-clavicular line are usually each 19–21 cm while Microsurgery DOI 10.1002/micr
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from nipple to IMF is 5–6 cm. These measurements offer guidelines for modifying the breast, and must be individualized based on proportionality and variances in chest wall anatomy. We chose to locate NAC at 23 cm from the sternal notch because of the patients’ characteristic such as height, BMI, and breast size. Adjustments of standard WP measurements were applied to improve DIEP flap insetting avoiding any risk of venous congestion and achieving symmetry with contralateral side in volume, shape and projection. Whenever SSMIV/SSM-V (planning type-1,4) was planned, WP incisions were easily marked bilaterally with some modification if tumor was located in the upper pole or in case of horizontally oriented scar incision in the medial/lateral upper pole from previous lumpectomy/quadrantectomy as previously described.12 If vertical scar incision from previous lumpectomy/quadrantectomy was located in the upper pole (planning type-2), the use of “inverted WP” allowed the option to spare breast skin rather than to perform MRM because of the high risk of mastectomy skin necrosis performing SSM-IV. In irradiated/ smoker patient with horizontally oriented scar incision in the medial/lateral upper pole from previous lumpectomy/quadrantectomy or in a smoker patient without previous surgery (planning type-3), a DMOP was applied. The idea to perform mastectomy through this new pattern was based on a previous study that pointed out that the geometry of WP may account for a decreased vascularity because mastectomy skin flaps maintain blood supply only from superior, lateral and medial branches while in that way skin flaps maintain blood supply from all directions.26 If lumpectomy/quadrantectomy was performed through a circum-areolar or vertical incision in irradiated/smoker patients, all types of SSM incision were considered at high risk of skin flap, NAC complication, and necrosis. In that case, MRM was preferred rather than the risk of reconstruction failure. If radiotherapy was already planned following mastectomy or a patient was considered a potential candidate to perform it because of the tumor histology and lymph-node involvement, a delayed reconstruction was preferred. Berrino et al. provided adequate guidelines for preoperative markings in postmastectomy patients who underwent transverse rectus abdominis musculocutaneous flap reconstruction.27 The authors did not take into account the possibility to perform an immediate contralateral symmetrization procedure, whenever required. In case of immediate or delayed reconstruction following MRM (planning type-5,6), the revised contralateral breast had to be used as a “footprint” for the breast to be reconstructed. Unusual orientation of the postmastectomy scar can complicate the preoperative markings that were suggested. However, the existing scar can Microsurgery DOI 10.1002/micr
be modified to achieve a suitable scar location and then to better allocate the flap. If additional skin resection is needed, this should be added to the measurements of skin defect when DIEP flap size is planned. Breast skin in the upper pole should be spared as much as possible so to avoid visible scar in the decollete. At our institution immediate reconstruction is the preferred choice, if it can be safely performed. Rosson et al described preoperative quality of life among women undergoing immediate, delayed, or major revision breast reconstructive surgery. The three groups differed significantly across four of the six domains: body image, psychosocial well-being, sexual well-being, and physical well-being of the chest and upper body. The immediate reconstruction group had higher scores than the delayed reconstruction and the major revision groups.28 In patients of both groups no preoperative volume asymmetry was observed between breasts and in delayed reconstruction the mastectomy weight was previously recorded allowing the possibility to simply achieve symmetry. Further studies are needed to evaluate the feasibility of our symmetrization algorithm with complementary device in surgeon volume estimation, whenever either breast asymmetry is observed or mastectomy weight is unknown.29 Patient and surgeon aesthetic survey demonstrated an overall positive opinion of reconstruction in both groups as youthful, normal appearing with good symmetry. Patients had very good to excellent general appearance with high to very high satisfaction in Group-A and very high satisfaction to satisfied in Group-B. Although no statistical difference was found between groups, the slight difference on patient satisfaction could have been influenced by the prolonged time to complete reconstruction in Group-B. All sub-items had substantial reliability between surgeons and moderate-substantial correlation was also observed between patient and surgeon surveys. Although our results are encouraging, we recognize that the study’s limitation was the selection bias (one stage vs. taged procedure) due to the retrospective report. Moreover, no comparisons of data between immediate and staged groups from each planning type of symmetrization were reported because of the small clinical series of patients. Larger studies are required to provide definitive guidance to surgeons performing a planned one-stage reconstruction in different clinical situations and types of reconstruction. CONCLUSION
One-stage DIEP flap reconstruction by means of the symmetrization algorithm resulted in comparable
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aesthetic outcomes and patient satisfaction to a staged procedure. CONFLICT OF INTEREST
The authors have submitted for publication on International Microsurgery a manuscript entitled: “One- stage DIEP flap reconstruction: algorithm for immediate contralateral breast symmetrization”. They, hereby certify, that to the best of our knowledge no financial support or benefits have been received by any author, by any member of our immediate family or any individual or entity with whom or with which they have a significant relationship from any commercial source, which is related directly or indirectly to the scientific work which is reported on in the article. Faithfully, Fabio Santanelli di Pompeo MD, PhD Rosaria Laporta MD Benedetto Longo MD, PhD Michail Sorotos MD Marco Pagnoni MD
REFERENCES 1. Losken A, Carlson GW, Bostwick J III, Jones GE, Culbertson JH, Schoemann M. Trends in unilateral breast reconstruction and management of the contralateral breast: the emory experience. Plast Reconstr Surg 2002;110:89–97. 2. Stevenson TR, Goldstein JA. TRAM flap breast reconstruction and contralateral reduction or mastopexy. Plast Reconstr Surg 1993;92: 228–233. 3. Huang JJ, Wu CW, Leon Lam W, Lin CY, Nguyen DH, Cheng MH. Simultaneous contralateral breast reduction/mastopexy with unilateral breast reconstruction using free abdominal flaps. Ann Plast Surg 2011;67:336–342. 4. Haykal S, Guay N. One hundred forty-one consecutive attempts at autologous tissue single-stage breast cancer reconstruction. Ann Plast Surg 2009;63:21–27. 5. Smith ML, Clarke-Pearson EM, Vornovitsky M, Dayan JH, Samson W, Sultan MR. The efficacy of simultaneous breast reconstruction and contralateral balancing procedures in reducing the need for second stage operations. Arch Plast Surg 2014;4:535–541. 6. Chang DW, Kroll SS, Dackiw A, Singletary SE, Robb GL. Reconstructive management of contralateral breast cancer in patients who previously underwent unilateral breast reconstruction. Plast Reconstr Surg 2001;108:352–358. discussion 359-360. 7. Labandter HP, Dowden RV. Surgical considerations in managing the remaining breast during postmastectomy breast reconstruction. Clin Plast Surg 1984;11:365–368. 8. Teunis T, van Voss MR, Kon M, van Maurik JF. CT-angiography prior to diep flap breast reconstruction: A systematic review and meta-analysis. Microsurgery 2013;33:496–502. 9. Cohen M, Evanoff B, George LT, Brandt KE. A subjective rating scale for evaluating the appearance outcome of autologous breast reconstruction. Plast Reconstr Surg 2005;116:440–449. 10. Cohen J. A coefficient of agreement for nominal scale. Educat Psychol Measure 1960;20:37–46.
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11. Landis JR, Koch GG. The measurement of observer agreement for categorical data. Biometrics 1977;33:159–174. 12. Carlson GW, Bostwick J3, Styblo TM, Moore B, Bried JT, Murray DR, Wood WC. Skin-sparing mastectomy. Oncologic and reconstructive considerations. Ann Surg 1997;225:570–575. discussion 575-578. 13. Santanelli F, Paolini G, Campanale A, Longo B, Amanti C. The “type V” skin-sparing mastectomy for upper quadrant skin resections. Ann Plast Surg 2010;65:135–139. 14. Haykal S, Guay N. One hundred forty-one consecutive attempts at autologous tissue single-stage breast cancer reconstruction. Ann Plast Surg 2009;63:21–27. 15. Huang JJ, Wu CW, Leon Lam W, Lin CY, Nguyen DH, Cheng MH. Simultaneous contralateral breast reduction/mastopexy with unilateral breast reconstruction using free abdominal flaps. Ann Plast Surg 2011;67:336–342. 16. Blondeel PN. One hundred free DIEP flap breast reconstructions: a personal experience. Br J Plast Surg 1999;52:104–111. 17. Koshima I, Soeda S. Inferior epigastric artery skin flap without rectus abdominis muscle. Br J Plast Surg 1989;42:645–648. 18. Allen RJ, Treece P. Deep inferior epigastric perforator flap for breast reconstruction. Ann Plast Surg 1994;32:32–38. 19. Santanelli F, Longo B, Angelini M, Laporta R, Paolini G. Prospective computerized analyses of sensibility in breast reconstruction with non-reinnervated DIEP flap. Plast Reconstr Surg 2011;127: 1790–1795. 20. Santanelli F, Longo B, Cagli B, Pugliese P, Sorotos M,, Paolini G. Predictive and protective factors for partial necrosis in DIEP flap breast reconstruction: Does nulliparity bias flap viability? Ann Plast Surg 2015;74:47–51. 21. Colakoglu S, Khansa I, Curtis MS, Yueh JH, Ogunleye A, Haewyon C, Tobias AM, Lee BT. Impact of complications on patient satisfaction in breast reconstruction. Plast Reconstr Surg 2011;127:1428– 1436. 22. Zhong T, McCarthy C, Min S, Zhang J, Beber B, Pusic AL, Hofer SO. Patient satisfaction and health-related quality of life after autologous tissue breast reconstruction: A prospective analysis of early postoperative outcomes. Cancer 2012;118:1701–1709. 23. Santanelli Di Pompeo F, Longo B, Sorotos M, Pagnoni M, Laporta R. The axillary versus internal mammary recipient vessel sites for breast reconstruction with diep flaps: A retrospective study of 256 consecutive cases. Microsurgery 2015;35:34–38. 24. Lantieri LA, Mitrofanoff M, Rimareix F, Gaston E, Raulo Y, Baruch JP. Use of circumflex scapular vessels as a recipient pedicle for autologous breast reconstruction: A report of 40 consecutive cases. Plast Reconstr Surg 1999;104:2049–2053. 25. Dabernig J, Ong KO, McGowan R, Wiberg M, Payne AP, Hart AM. The anatomic and radiologic basis of the circumflex scapular artery perforator flap. Ann Plast Surg 2010;64:784–788. 26. Lin IC, Bergey M, Sonnad SS, Serletti JM, Wu LC. Management of the ptotic or hypertrophic breast in immediate autologous breast reconstruction: A comparison between the wise and vertical reduction patterns for mastectomy. Ann Plast Surg 2013;70:264– 270. 27. Berrino P, Santi P. Preoperative TRAM flap planning for postmastectomy breast reconstruction. Ann Plast Surg 1988;21:264–272. 28. Rosson GD, Shridharani SM, Magarakis M, Manahan MA, Basdag B, Gilson MM, Pusic AL. Quality of life before reconstructive breast surgery: A preoperative comparison of patients with immediate, delayed, and major revision reconstruction. Microsurgery 2013;33: 253–258. 29. Longo B, Farcomeni A, Ferri G, Campanale A, Sorotos M, Santanelli F. The BREAST-V: A unifying predictive formula for volume assessment in small, medium, and large breasts. Plast Reconstr Surg 2013;132:1e–7e.
Microsurgery DOI 10.1002/micr
The aim of this study was to investigate clinical and aesthetic results of simultaneous contralateral balancing procedures in unilateral DIEP flap reconstructions by means of a symmetrization algorithm. Between 2004 and 2013, 335 patients underwent DIEP flap breast reconstruction with 48 patients (mean age 51.8 years, range 32–69 years) undergoing contralateral procedure. Patients were divided in Group-A including 31 cases who underwent one-stage procedure and Group-B including 17 cases who underwent staged procedure. A symmetrization algorithm was proposed to plan immediate breast reduction/mastopexy. The groups were homogeneous regarding patient’s age, BMI, mastectomy and flap weight (P > 0.05). All flaps survived. No complications were observed to the mastectomy skin flaps and to the reduction mammaplasty/mastopexy procedures in both groups. The mean operation time was 5 h in Group-A while 5 h and 37 min in Group-B (P 5 0.0682). Contralateral procedures included 23 breast reductions and 8 mastopexies in Group-A, while 10 breast reductions and 7 mastopexies were performed in Group-B. Two and 6 patients required revision of the balancing procedure in Group-A and Group-B, respectively. The follow-up time was 47.3 months (range 14–120 months) in Group-A and 91.3 months (range 41– 110 months) in Group-B. Volume, upper/lower pole shape, projection, breast mound placement, IMF, symmetry, overall appearance, and general satisfaction sub-items obtained high-score evaluation without significant difference between the two groups (P > 0.05). One-stage DIEP flap reconstruction by means of the symmetrization algorithm resulted in comparable aesthetic outcomes and patient satisfaction to C 2015 Wiley Periodicals, Inc. Microsurgery 36:7–19, 2016. a staged procedure. V
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definition of a satisfactory outcome is not only survival through total eradication of breast cancer but also a symmetrical and aesthetically pleasing breast reconstruction. This often requires additional balancing procedures to the contralateral side in the form of augmentation, reduction, or mastopexy.1–3 The decision to carry on with either an immediate or a staged procedure is often subjective in both implant and autologous reconstruction. Advocates of the simultaneous technique describe the advantages of using the revised contralateral breast as a “footprint” for the reconstructed breast to achieve symmetry in one-stage, decreasing patient morbidity, reoperation time, improving patients’ quality of life and reducing costs in an already overburdened health-care system.4,5 Conversely, some surgeons prefer to perform a staged procedure because of the potential disadvantages of a one-stage procedure such as longer operating times, blood loss, difficulty in achieving pleasant long-term symmetry, and eventual modification by adjuvant radiotherapy.6,7 In literature, no reports focus attention on the need of an algorithm to plan breast symmetrization in different types of clinical conditions to optimize shape, volume, and projection symmetry avoiding secondary revision surgery if one-stage reconstruction is scheduled. The objectives of this study were Plastic Surgery Department, Sant’andrea Hospital, School of Medicine and Psychology, “Sapienza” University of Rome, Rome, Italy *Correspondence to: Fabio Santanelli di Pompeo, M.D., Ph.D., Via di Grottarossa 1035-1039, 00189 Rome, Italy. E-mail: [email protected] Received 30 September 2014; Revision accepted 18 January 2015; Accepted 13 February 2015 Published online 2 March 2015 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/micr.22390 Ó 2015 Wiley Periodicals, Inc.
to investigate the clinical and aesthetic outcomes of one-stage deep inferior epigastric perforator (DIEP) flap breast reconstruction by means of a symmetrization algorithm. PATIENTS AND METHODS
A retrospective review was performed of patients undergoing DIEP flap transfer after mastectomy, from May 2004 to September 2013, by the senior surgeon (FSdP) at a single cancer center. A total of 335 women had reconstruction following mastectomy among which 16 (4.8%) were bilateral and 319 (95.3%) unilateral. All patients received preoperative Computerized-Tomography Angiography to evaluate the flap perforators’ pattern, which, as other studies confirm, proved helpful in identifying the ideal perforator.8 However, we did not perform any radiologic study for the recipient vessels. Inclusion criteria were unilateral reconstruction with contralateral mastopexy/reduction procedure and followup at least 1 year after primary surgery. Scar revisions and minor revisions performed under local anesthesia were not evaluated. Six different clinical situations were identified and for each of them a preoperative planning was developed to reach symmetry in one-stage procedure, and classified according to incision pattern. In all cases, the median breast line was marked and then the new nipples were positioned along it 23 cm from the sternal notch. Planning type-1 (Wise-pattern, WP): when skinsparing mastectomy (SSM) type IV was indicated on affected breast because of the tumor located in the lower pole,9 WP incisions were marked bilaterally. New
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Figure 1. Planning type-1 (WP). The median breast line was marked, the new nipples were positioned along it approximately at 23 cm from the sternal notch. WP incisions were marked bilaterally. New NAC was measured 5 cm (A); the lateral arms of the pattern were measured 6–8 cm (B) and the distance between them was 5–7 cm (C). DIEP flap markings with round skin paddle and the deepithelialized area (pink color) of the flap (D).
Figure 2. A 46-year-old woman with previous left breast periareolar lumpectomy scar underwent immediate one-stage reconstruction following left SSM-IV. Preoperative and postoperative frontal view.
nipple-areola complex (NAC) was measured 5 cm with a radius of 2.5 cm; the lateral arms of the pattern were measured 6–8 cm rather than 5 cm while the distance between them was 5–7 cm rather than 9 cm (Figs. 1 and 2). Planning type-2 (Inverted WP): in case of vertical scar incision from previous lumpectomy/quadrantectomy Microsurgery DOI 10.1002/micr
located in the upper pole, the “inverted WP” was drawn turning of 180 the pattern on the affected breast, while “standard” pattern was marked on the contralateral side. Same principles regarding WP measurements were applied to both sides. The vertical scar was included in the upper pole skin resection area matching the contralateral (reduction/mastopexy) resection area. To position
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Figure 3. Planning type-2 (Inverted WP). The “ inverted WP” was drawn turning of 180 the pattern on the affected breast, while “ standard” pattern was marked on the contralateral side. The vertical scar was included in the upper pole skin resection area (i.e., B 5 10 cm in height) matching the contralateral (reduction/mastopexy) resection area (i.e., A 5 10 cm in height). NAC on the affected breast was located at 33 cm from the sternal notch (23 cm 1 B). DIEP flap markings with a round skin paddle and the de-epithelialized area (pink color) of the flap (C).
Figure 4. A 56-year-old woman, with previous vertical right breast quadrantectomy in the upper pole underwent immediate one-stage reconstruction following “ inverted WP.” Preoperative and postoperative frontal view.
NAC at 23 cm from the sternal notch on the affected breast, the distance was calculated taking into account the area of skin resection from the upper pole; if the latter was 10 cm in height, NAC was located at 33 cm from the sternal notch (Figs. 3 and 4). Planning type-3 (Double-mirrored omega pattern, DMOP): in case of horizontally oriented scar incision
in the medial/lateral upper pole from previous lumpectomy/quadrantectomy in irradiated/smoker patient or in a smoker patient without previous surgery, a DMOP was applied on the affected breast. NAC was located at 23 cm from sternal notch on both breasts. Centering on this point, the upper areola semicircle was drawn with a radius of 2.5 cm on the affected Microsurgery DOI 10.1002/micr
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Figure 5. Planning type-3 (DMOP). NAC position was located at 23 cm from sternal notch on both breasts. Centering on this point, the upper areola semicircle was drawn while the lower areola semicircle is marked at the distance to IMF (A) equal to the length of the lateral arms of contralateral WP (B). On the unaffected breast “ standard” WP was applied. DIEP flap markings with a round skin paddle and the de-epithelialized area (pink color) of the flap (C).
Figure 6. A 52-year-old-smoker woman underwent immediate one-stage reconstruction following DMOP. Preoperative and postoperative frontal view.
side, while the lower areola semicircle was marked at the distance to inframammary fold (IMF) equal to the length of the lateral arms of contralateral WP. Finally, both ends of the two semicircles were connected to the medial and lateral borders of the breast. On the unaffected breast, “standard” WP was applied (Figs. 5 and 6). Microsurgery DOI 10.1002/micr
Planning type-4 (SSM-V): in case of horizontally oriented scar incision in the medial/lateral upper pole from previous lumpectomy/quadrantectomy in nonirradiated/ nonsmoker patient or if the tumor was superficially located in the medial/lateral upper pole, a “modified WP” for upper quadrant skin resection (SSM-V) was applied.10 “Standard WP” was used to perform
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Figure 7. Planning type-4 (SSM-V). “ Modified WP” for upper quadrant skin resection (SSM-V) was applied. “ Standard WP” was used to perform mastopexy/reduction on the opposite breast. Same principles regarding WP measurements were applied. DIEP flap markings with a round skin paddle and the de-epithelialized area (pink color) of the flap (D).
Figure 8. A 55-year-old woman, with previous horizontally oriented quadrantectomy scar in the lateral upper pole, underwent immediate one-stage reconstruction following SSM-V. Preoperative and postoperative frontal view.
mastopexy/reduction on the opposite breast (Figs. 7 and 8). Same principles regarding WP measurements were applied. Planning type-5 (MRM-Immediate reconstruction): if modified radical mastectomy (MRM) was to be performed, height (MRM-H) and width (MRM-W) of the planned
elliptical excision were recorded. Then, WP was applied on the unaffected breast with NAC at 23 cm from sternal notch and vertical branches of 6–8 cm in length according to the desired final volume (Figs. 9 and 10). MRM-H minus the height of lower pole skin reduction on the contralateral breast was equal to the length of the minor axis Microsurgery DOI 10.1002/micr
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Figure 9. Planning type-5 (MRM-Immediate reconstruction). Height (MRM-H) and width (MRM-W) of the planned elliptical excision are recorded. WP was applied on the unaffected breast. MRM-H minus the height of lower pole skin reduction on the contralateral breast (A) was equal to the length of the minor axis of the DIEP flap skin paddle (C), while MRM-W minus the distance between the vertical WP branches (B) was the length of the major axis (D). The subcutaneous defect on the upper portion of mastectomy side was restored including to the DIEP flap skin ellipse the available deepithelialized abdominal tissue (D).
Figure 10. A 54-year-old woman underwent immediate one-stage reconstruction following left MRM. Preoperative and postoperative frontal view.
of the DIEP flap skin paddle, while MRM-W minus the distance between the vertical WP branches (on the unaffected breast) was the length of the major axis. Planning type-6 (MRM-Delayed reconstruction): WP was applied on the unaffected breast with NAC at 23 cm from sternal notch and with the vertical branches 6–8 cm in length according to desired final volume. The IMF was marked on the unaffected side, and a line symmetrical (a) Microsurgery DOI 10.1002/micr
to it was drawn on the mastectomy side. From the sternal notch to new IMF, passing through the new nipple position, a line (b) was drawn on the unaffected breast; a similar line (c) was drawn on the mastectomy side reaching line a. Lines b and c were measured: the difference between them and the amount of scar tissue resection (line d) provided the skin deficit on the affected side and the length of the minor axis of the DIEP flap skin paddle. Because of the
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Figure 11. Planning type-6 (MRM-Delayed reconstruction).WP was applied on the unaffected breast. Line a symmetrical to IMF on the unaffected was marked on the mastectomy side. From the sternal notch to new IMF, passing through the new nipple position, line b was drawn on the unaffected breast; line c was drawn on the mastectomy side reaching line a. b 2 c 1 d 1 (2–4 cm) 5 the length of the minor axis of the DIEP flap skin paddle (D). The breast equator (AB) minus the distance between the two vertical WP branches (C) 5 the length of the major axis of the DIEP flap skin paddle (E). The subcutaneous defect on the upper portion of mastectomy side was restored including to the DIEP flap skin ellipse the available de-epithelialized abdominal tissue (F).
Figure 12. A 44-year-old woman underwent delayed DIEP flap reconstruction and contralateral breast procedure following right MRM. Preoperative and postoperative frontal view.
degree of skin tension from the previous mastectomy, 2– 4 cm was added to this difference (lines b 2 c 1 d). The breast equator (from point A to B) minus the distance between the two vertical WP branches on the unaffected
breast was the length of the major axis of the DIEP flap skin paddle (Figs. 11 and 12). The subcutaneous defect on the upper portion of mastectomy side was restored including to the DIEP flap Microsurgery DOI 10.1002/micr
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Figure 13. Breast symmetrization algorithm. MRM: modified radical mastectomy; SSM-V: skin sparing mastectomy type V.
skin ellipse the available deepithelialized abdominal tissue (C). In all cases described, the volume resection of the unaffected breast and the flap weight was established according to the mastectomy weight. This means that if the latter was 1000 g, the contralateral breast might have been reduced of 300 g, while flap weight of 700 g was required to perform reconstruction. Lumpectomy/quadrantectomy weight, if previously performed, was added to desired breast reduction weight. Breast symmetrization algorithm was summarized in Figure 13. Patients were divided in Group-A including those who underwent contralateral symmetry procedure in onestage and Group-B including those who underwent a staged procedure. Aesthetic and non-aesthetic complications were evaluated. The aesthetic complications included: malposition, volume deficiency/excess of the reconstructed breast and contralateral breast revision. The nonaesthetic complications included mastectomy flap necrosis, partial/total flap loss, venous thrombosis, arterial thrombosis, and donor site complications. Demographic data (age, BMI), reconstruction timing, mastectomy and flap weight, volume of breast tissue removed on the contralateral side, hospital stay, type of symmetry procedure, number of take-backs to the theater for secondary procedures were also entered. Aesthetic analysis was also done by pre and postoperative digital photographs to grade aesthetic results, at least 12 months follow-up, by patients and blinded plastic surgeons (2 independent observers) who were uninvolved in these reconstructive series. The grading scale applied was a modification of that original described by Microsurgery DOI 10.1002/micr
Cohen et al.11 Volume, upper pole and lower pole shape, projection, placement of the breast mound on the chest wall, IMF, symmetry, overall appearance, and general satisfaction were scored ranging from 1 to 5 (Table 1). Inter-rater reliability was calculated for each of the picture grading subscales using the Cohen’s Kappa.12 The strength of agreement was classified based on the Œ score as follows: less than 0.00, poor; 0.00 to 0.20, slight; 0.21 to 0.40, fair; 0.41 to 0.60, moderate; 0.61 to 0.80, substantial; and 0.81 to 1.00, almost perfect agreement.13 Continuous and categorical variables were analyzed using student t test and Kruskal-Wallis test, respectively. A value of P 0.05 was considered statistically significant. RESULTS Clinical Outcomes
The two groups were homogeneous regarding patient’s age, BMI, mastectomy and flap weight (P > 0.05) (Table 2). Group-A included 31 patients, 27 had immediate reconstruction, of which 17 following SSM and 10 following MRM, while 4 patients had delayed reconstruction. Planning type-1 was performed in 7 patients, type-2 in 3 patients, type-3 in 6 patients, type 4-6 in 5 patients for each. Group-B included 17 patients of which 8 had immediate reconstruction and 9 delayed one following MRM in all cases. Twenty-two flaps were anastomosed to circumflex scapular vessels (CSV), 6 to thoracodorsal vessels (TDV), and 3 to internal mammary vessels (IMV) in Group-A, while 4 flaps were anastomosed to CSV, 6 to TDV, and 7 to IMV in Group-B.
Volume, upper pole and lower pole shape, breast’s projection, placement of the breast mound, IMF, symmetry, overall appearance, and general satisfaction were scored ranging from 1 to 5.
Unacceptable Unacceptable Very dissatisfied Good Good Satisfied Very good Very good High
Placement of the breast mound on the chest wall (vertical position) Placement of the breast mound on the chest wall (horizontal position) IMF
Upper pole shape Lower pole shape Breast’s projection
Symmetry Overall appearance General satisfaction
A perfectly naturalappearing, continuous fold with a gentle, smooth curve Excellent Excellent Very high
Poor Poor Dissatisfied
Undetectable IMF Discontinuous fold but gentle, smooth curve A natural-appearing, continuous fold with a gentle, smooth curve
Extremely far laterally
Discontinuous fold and irregular curve
Moderately far medially Moderately far laterally
Very good resemblance Very good resemblance Very good: very youthful appearing breast Extremely far superiorly
Perfectly/normally/ideally Extremely far medially
Very Mild discrepancy relative to contralateral side Very poor resemblance Very poor resemblance Very poor: very aged appearing breast Moderately far superiorly Marked discrepancy relative to contralateral side Poor resemblance Poor resemblance Poor: aged appearing breast Extremely far inferiorly Mild discrepancy relative to contralateral side Good resemblance Fair resemblance Good resemblance Fair resemblance Good: youthful appearing Fair breast Moderately far inferiorly Perfectly/normally/ideally Symmetrical Very symmetrical Volume
Score 3 Score 2 Score 1 Subitems
Table 1. Subscale Analysis of Breast Reconstruction
Score 4
Score 5
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The choice of adopting one-stage procedure instead of the staged one changed during the years; Group-A were patients in the later part of the time period reviewed while Group-B was in the earlier part. Patients were discharged on mean 5.6th postoperative day (range 5–7 days) in Group-A and on 5.5th day (range 5–8 days) in Group-B with no statistical difference (P 5 0.601). All flaps completely survived but one in Group-A (type-5) developed a venous congestion leading to a partial necrosis of zone III, which was debrided on day 10 without further procedure to optimize symmetry. No complications were observed to the mastectomy skin flaps and to the reduction mammaplasty/mastopexy procedures with regards to skin necrosis, nipple areolar partial/total loss, hematoma, and fat necrosis in both groups. Mean operation time was 5 hours (range, 3 hours and 50 minutes to 6 hours) in Group-A while 5 hours and 37 minutes (range, 5 hours to 6 hours and 25 minutes) in Group-B, which was not statistically significant (P 5 0.0682). In Group-A 23 breast reductions and 8 mastopexies were performed with a mean reduction weight of 168 gr (range 100–350) while in Group-B were performed 10 breast reductions and 7 mastopexies with a mean reduction weight of 147 gr (range 100– 230). The average time between primary surgery and contralateral procedure was 10.80 months (range 5–36 months) in Group-B. The range of secondary procedures and their incidence in both groups are shown in Table 3. Mean number of take-back was not calculated because only two patients required revision of the contralateral balancing procedure in Group-A. Conversely, at a mean follow-up of 27 months (range, 24–36 months), in Group-B 2 patients required additional revision of the reconstructed breast by liposuction, 4 of the previous reduction mammaplasty, while 2 cases of the mastopexy. Revision of the reconstructed breast and of the previous mastopexy/breast reduction was considered aesthetic complications. No patients experienced postoperative radiation therapy. The follow-up time from primary oncological surgery to aesthetic evaluation was 47.30 months (range 14– 120 months) in Group-A and 91.30 months (range, 41– 110 months) in Group-B. None of the reduced breast tissue revealed breast cancer in the final histological examination. Aesthetic Results
Volume, upper pole and lower pole shape, breast’ projection, placement of the breast mound, IMF, symmetry, overall appearance and general satisfaction subitems got high score evaluation without significant difference between survey results from Group-A and Group-B patients and surgeons (P > 0.05) (Tables 4 and 5). InterMicrosurgery DOI 10.1002/micr
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Laporta et al. Table 2. Patients’ Data and P Values from the Continuous Variables Mean patient’age (years)
Mean BMI (kg/m2)
Mean mastectomy Weight (gr)
Mean flap weight (gr)
52.2 (range 32–69) 51.3 (range 33–63) 0.164
27.7 (range 25–31) 27.6 (range 24–30) 0.840
753 (range 500–1150) 722 (range 550–980) 0.893
615 (range 500–800) 632 (range 500–850) 0.552
Group-A Group -B P-value BMI: body max index.
Table 3. Range of Procedures and Their Incidence in Group-A and Group-B Group-A
Group-B Planned procedure Additional unplanned procedure
Secondary procedures Lipofilling of the reconstructed breast Liposuction of the reconstructed breast Mastopexy Reduction mammaplasty Revision of mastopexy Revision of reduction mammaplasty
rater agreement between surgeon observers was substantial for all subitems while it was moderate-substantial between surgeon and patient evaluations. DISCUSSION
Although good, consistent result is sometimes possible with a unilateral DIEP flap reconstruction, contralateral procedures are often required to achieve symmetric breast mounds. Few articles are published on this topic, especially concerning how to plan simultaneous procedures in a single stage. Stevenson and Goldstein compared TRAM flap and immediate contralateral breast reduction/mastopexy with TRAM flap alone; their results suggested that performing the combined procedure was safe and yielded a satisfactory aesthetic result.2 Losken et al. presented a series of 1394 patients, but they did not compare outcomes between simultaneous and staged procedures.1 Hakyal and Guay reported a single-stage autologous reconstruction by the use of pedicled flaps (25.8%) and free flaps (75.2%) with 11.3% of postoperative aesthetic complications in 141 patients, the most common being volume excess (5.7%) followed by malposition (2.1%), volume loss due to weight loss (1.4%), asymmetry of shape (1.4%), and volume deficiency (0.7%).14 Huang et al. also performed a study focusing on DIEP and superficial inferior epigastric artery flaps comparing clinical and aesthetic outcomes in immediate and staged contralateral surgery. They claimed greater patient satisfaction, minimal increase in operative time, and no increase in complication rates.15 Free tissue transfer using DIEP flap is considered by many to be the preferred choice for autologous Microsurgery DOI 10.1002/micr
n (%)
n (%)
2 2 2 2 2 2/31 (6.5%)
7/17 (41.2%) 6/17 (35.3%) 2/17 (11.8%) 7/17 (41.2%) 10/17 (58.8%) 2/20 (11.8%) 4/20 (24.5%)
reconstruction,16220 having higher short- and long-term patient satisfaction, along with improved psychosocial and sexual well being.21,22 Extra time is often needed in flap harvest because of the intramuscular perforator’s course and contralateral procedure can discourage surgeons due to the theoretical increase in operating time. Furthermore partial or complete flap failure or radiotherapy damage may result in additional take-backs to the theater and troubles performing revision on the reconstructed breast and on already reduced contralateral side in attempt to preserve symmetry. No statistical difference was found between groups regarding mean operative time and patients discharge. In our practice, DIEP flap harvest, mastectomy procedure, and recipient vessels dissection were routinely performed simultaneously. The flap was transferred, rotated 180 and fixed temporarily to the chest wall; both arterial and venous anastomoses were performed while donor site closure was carried out by a second team. Next, the senior surgeon completed flap insetting while the senior assistant performed the contralateral procedure. The recipient vessels selection changed during the year showing an inversion of the trend between TDV and CSV and a continuous decrease of the IMV. We believe that CSV can be safely used as recipient vessels both for immediate and delayed reconstructions due to easier dissection compared to the one for the IMV because of their anatomical characteristics; greater and more constant caliber than the IMV perforator vessels; optimal flap insetting due to the pedicle’s length when dissected until its origin as previously described.23 Moreover, their location in the posterior axillary region does not expose them completely to the consequences of radiotherapy.24,25 Finally,
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Table 4. Patient Survey Results Mean Score
Volume Upper pole shape Lower pole shape Breast’s projection Placement of the breast mound on the chest wall (vertical position) Placement of the breast mound on the chest wall (horizontal position) IMF Symmetry Overall appearance General satisfaction
Group-A
Group-B
P
1.68 6 0.702 1.52 6 0.626 1.55 6 0.723 1.48 6 0.570 2.77 6 0.425
1.76 6 0.752 1.47 6 0.514 1.47 6 0.717 1.59 6 0.507 2.71 6 0.470
0.707 0.941 0.683 0.545 0.605
2.77 6 0.425
2.76 6 0.437
0.941
1.45 6 0.568 1.97 6 0.795 1.71 6 0.693 1.90 6 0.790
1.41 6 0.507 1.82 6 0.636 1.76 6 0.562 2.29 6 0.470
0.890 0.554 0.665 0.076
Group-A
Group-B
P
1.58 6 0.672 1.36 6 0.55 1.47 6 0.59 1.42 6 0.50 2.56 6 0.51
1.73 6 0.62 1.47 6 0.61 1.44 6 0.56 1.50 6 0.51 2.62 6 0.50
0.380 0.526 0.916 0.602 0.724
2.53 6 0.50
2.71 6 0.47
0.249
1.48 6 0.57 1.71 6 0.69 1.65 6 0.61
1.35 6 0.493 1.91 6 0.68 1.56 6 0.60
0.467 0.318 0.565
Table 5. Surgeon Survey Results Mean Score
Volume Upper pole shape Lower pole shape Breast’s projection Placement of the breast mound on the chest wall (vertical position) Placement of the breast mound on the chest wall (horizontal position) IMF Symmetry Overall appearance
their use does not influence the choice of alternative flaps such as latissimus dorsi flap. Operative time related to vessels selection was not assessed because it was not the aim of the current study. The choice of adopting one-stage procedure instead of the staged one changed from 2004 to date, since our approach regarding the preoperative planning for DIEP flap breast reconstructions changed as well. In the early experience of the senior surgeon, the choice of a onestage over a staged procedure was guided by the severity of breast hypertrophy, in order not to produce significant residual asymmetry following primary surgery. Moreover, formerly the longer operative time to harvest a DIEP flap was discouraging to perform an additional procedure simultaneously. Currently, all patients are considered eligible candidates to undergo a symmetrization procedure, unless they refuse surgery on the unaffected breast. From our experience seemed that mean operative time, clinical and aesthetic complication rate in DIEP flap reconstruction may be mostly related to surgeon experience and skills rather than multiple procedures in one-stage. Conversely, if multiple procedures are performed in more sessions by
different plastic surgeons, the incidence of take-backs for revision surgery could increase. In Group-A, only two patients required take-back to the theater while in GroupB all patients underwent secondary delayed procedures (reduction/mastopexy) and further 8 patients required additional revision surgery. We evaluated the number of take-backs to the theater rather than each procedure because multiple procedures can be performed simultaneously in only one session. The average time between breast reconstruction and contralateral surgery in Group-B was 10.80 months (range 5–36 months.). At our institution breast symmetrization was always offered to the patients within 6 months after primary surgery but some of them wished to delay it. Delayed take-backs to theater were probably influenced by negative patient cancer experience, extending the time to complete the reconstruction. In one-stage procedure, the main issue is how to plan DIEP flap reconstruction simultaneously to a conventional breast reduction/mastopexy. The ideal distances from the sternal notch to the nipple and from the mid-clavicular line are usually each 19–21 cm while Microsurgery DOI 10.1002/micr
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Laporta et al.
from nipple to IMF is 5–6 cm. These measurements offer guidelines for modifying the breast, and must be individualized based on proportionality and variances in chest wall anatomy. We chose to locate NAC at 23 cm from the sternal notch because of the patients’ characteristic such as height, BMI, and breast size. Adjustments of standard WP measurements were applied to improve DIEP flap insetting avoiding any risk of venous congestion and achieving symmetry with contralateral side in volume, shape and projection. Whenever SSMIV/SSM-V (planning type-1,4) was planned, WP incisions were easily marked bilaterally with some modification if tumor was located in the upper pole or in case of horizontally oriented scar incision in the medial/lateral upper pole from previous lumpectomy/quadrantectomy as previously described.12 If vertical scar incision from previous lumpectomy/quadrantectomy was located in the upper pole (planning type-2), the use of “inverted WP” allowed the option to spare breast skin rather than to perform MRM because of the high risk of mastectomy skin necrosis performing SSM-IV. In irradiated/ smoker patient with horizontally oriented scar incision in the medial/lateral upper pole from previous lumpectomy/quadrantectomy or in a smoker patient without previous surgery (planning type-3), a DMOP was applied. The idea to perform mastectomy through this new pattern was based on a previous study that pointed out that the geometry of WP may account for a decreased vascularity because mastectomy skin flaps maintain blood supply only from superior, lateral and medial branches while in that way skin flaps maintain blood supply from all directions.26 If lumpectomy/quadrantectomy was performed through a circum-areolar or vertical incision in irradiated/smoker patients, all types of SSM incision were considered at high risk of skin flap, NAC complication, and necrosis. In that case, MRM was preferred rather than the risk of reconstruction failure. If radiotherapy was already planned following mastectomy or a patient was considered a potential candidate to perform it because of the tumor histology and lymph-node involvement, a delayed reconstruction was preferred. Berrino et al. provided adequate guidelines for preoperative markings in postmastectomy patients who underwent transverse rectus abdominis musculocutaneous flap reconstruction.27 The authors did not take into account the possibility to perform an immediate contralateral symmetrization procedure, whenever required. In case of immediate or delayed reconstruction following MRM (planning type-5,6), the revised contralateral breast had to be used as a “footprint” for the breast to be reconstructed. Unusual orientation of the postmastectomy scar can complicate the preoperative markings that were suggested. However, the existing scar can Microsurgery DOI 10.1002/micr
be modified to achieve a suitable scar location and then to better allocate the flap. If additional skin resection is needed, this should be added to the measurements of skin defect when DIEP flap size is planned. Breast skin in the upper pole should be spared as much as possible so to avoid visible scar in the decollete. At our institution immediate reconstruction is the preferred choice, if it can be safely performed. Rosson et al described preoperative quality of life among women undergoing immediate, delayed, or major revision breast reconstructive surgery. The three groups differed significantly across four of the six domains: body image, psychosocial well-being, sexual well-being, and physical well-being of the chest and upper body. The immediate reconstruction group had higher scores than the delayed reconstruction and the major revision groups.28 In patients of both groups no preoperative volume asymmetry was observed between breasts and in delayed reconstruction the mastectomy weight was previously recorded allowing the possibility to simply achieve symmetry. Further studies are needed to evaluate the feasibility of our symmetrization algorithm with complementary device in surgeon volume estimation, whenever either breast asymmetry is observed or mastectomy weight is unknown.29 Patient and surgeon aesthetic survey demonstrated an overall positive opinion of reconstruction in both groups as youthful, normal appearing with good symmetry. Patients had very good to excellent general appearance with high to very high satisfaction in Group-A and very high satisfaction to satisfied in Group-B. Although no statistical difference was found between groups, the slight difference on patient satisfaction could have been influenced by the prolonged time to complete reconstruction in Group-B. All sub-items had substantial reliability between surgeons and moderate-substantial correlation was also observed between patient and surgeon surveys. Although our results are encouraging, we recognize that the study’s limitation was the selection bias (one stage vs. taged procedure) due to the retrospective report. Moreover, no comparisons of data between immediate and staged groups from each planning type of symmetrization were reported because of the small clinical series of patients. Larger studies are required to provide definitive guidance to surgeons performing a planned one-stage reconstruction in different clinical situations and types of reconstruction. CONCLUSION
One-stage DIEP flap reconstruction by means of the symmetrization algorithm resulted in comparable
Symmetrization Algorithm
aesthetic outcomes and patient satisfaction to a staged procedure. CONFLICT OF INTEREST
The authors have submitted for publication on International Microsurgery a manuscript entitled: “One- stage DIEP flap reconstruction: algorithm for immediate contralateral breast symmetrization”. They, hereby certify, that to the best of our knowledge no financial support or benefits have been received by any author, by any member of our immediate family or any individual or entity with whom or with which they have a significant relationship from any commercial source, which is related directly or indirectly to the scientific work which is reported on in the article. Faithfully, Fabio Santanelli di Pompeo MD, PhD Rosaria Laporta MD Benedetto Longo MD, PhD Michail Sorotos MD Marco Pagnoni MD
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Microsurgery DOI 10.1002/micr
