Plastic Surgery · Supplementary · from Plastic Surgery

Case 3: Breast Reconstruction with DIEP Flap

Patient Presentation

Demographics: 45-year-old female elementary school teacher

Chief Complaint: "I want breast reconstruction after my mastectomy for cancer"

History of Present Illness: This 45-year-old female elementary school teacher was diagnosed with left breast invasive ductal carcinoma 4 months ago after presenting with a palpable mass on self-examination. Core needle biopsy revealed a 2.8 cm ER+/PR+/HER2-negative invasive ductal carcinoma, grade 2. Genetic testing revealed she is a BRCA1 mutation carrier. After extensive counseling, she elected to undergo bilateral skin-sparing mastectomy with immediate reconstruction.

She completed neoadjuvant chemotherapy with dose-dense adriamycin and cyclophosphamide followed by weekly paclitaxel, achieving a near-complete clinical response. She strongly desires autologous tissue reconstruction rather than implant-based reconstruction, citing concerns about implant longevity and desire for a more natural result. She has adequate lower abdominal tissue for bilateral DIEP (Deep Inferior Epigastric Perforator) flap reconstruction. She has no prior abdominal surgeries.

The patient met with the reconstructive microsurgeon and after discussion of options including DIEP flap, TRAM flap, latissimus dorsi flap, and implant-based reconstruction, she chose bilateral DIEP flap reconstruction for the most natural result with minimal donor site morbidity.

Past Medical History:

• Newly diagnosed left breast invasive ductal carcinoma (ER+/PR+/HER2-, BRCA1+)
• Completed neoadjuvant chemotherapy 4 weeks ago
• Mild seasonal allergies
• No prior surgeries

Medications:

• Loratadine 10 mg daily as needed
• Ondansetron 4 mg as needed (post-chemotherapy)
• Prenatal vitamin (as general supplement)

Social History:

• Non-smoker, never smoked
• Occasional wine (1-2 glasses/week), none during chemotherapy
• Elementary school teacher
• Married with two children (ages 8 and 12)
• Regular exercise: jogging 3x/week, yoga 2x/week
• BMI 26 with adequate lower abdominal panniculus

Family History:

• Mother diagnosed with breast cancer at age 48 (BRCA1+)
• Maternal aunt with ovarian cancer at age 55
• Maternal grandmother with breast cancer at age 52

Physical Examination

• Vital Signs: BP 118/72 mmHg, HR 68 bpm, RR 14/min, Temp 36.7°C, SpO2 99% on room air, BMI 26.2, Weight 68 kg, Height 161 cm
• General: Well-appearing female in no acute distress, alopecia from chemotherapy with early regrowth
• Breasts: Left breast with 2 cm residual palpable mass at 10 o'clock position (decreased from 2.8 cm pre-chemotherapy). No skin changes, no nipple discharge. Right breast without masses. No axillary lymphadenopathy bilaterally
• Abdomen: Soft, non-tender. Adequate lower abdominal panniculus for bilateral flap harvest. No surgical scars. Pinch test >3 cm of subcutaneous tissue at the lower abdomen. No hernias detected
• Vascular Assessment: Palpable bilateral deep inferior epigastric artery perforators on handheld Doppler at paraumbilical locations
• Cardiac: Regular rate and rhythm, no murmurs
• Lungs: Clear to auscultation bilaterally
• Extremities: No edema, normal range of motion

Workup and Results

Laboratory Studies:

Imaging/Additional Studies:

• CT Angiography of the abdomen: Bilateral dominant deep inferior epigastric artery perforators identified. Right side: two large periumbilical perforators (1.2 mm and 1.0 mm diameter). Left side: one dominant periumbilical perforator (1.4 mm diameter). No anatomic variants
• Breast MRI (post-chemotherapy): 1.2 cm residual enhancement at the known tumor site in the left breast, consistent with partial response. Right breast unremarkable
• Staging PET-CT: No evidence of metastatic disease
• Genetic testing: BRCA1 pathogenic variant (c.68_69delAG)
• Oncotype DX: Recurrence score 18 (intermediate risk)

Clinical Image

Diagram illustrating the DIEP flap harvest from the lower abdomen, showing perforator vessels passing through the rectus abdominis muscle (which is preserved) and microsurgical anastomosis to the internal mammary vessels for breast mound reconstruction. Source: Educational illustration.

Diagnosis

Left Breast Invasive Ductal Carcinoma (ER+/PR+/HER2-, BRCA1+) Status Post Neoadjuvant Chemotherapy, Planned Bilateral Skin-Sparing Mastectomy with Immediate Bilateral DIEP Flap Reconstruction

Key Diagnostic Criteria:

• Biopsy-proven invasive ductal carcinoma with favorable receptor status
• BRCA1 mutation carrier warranting bilateral mastectomy
• CT angiography confirming suitable perforator anatomy for DIEP flap
• Adequate abdominal donor tissue with BMI 26.2 and no prior abdominal surgery

Treatment Plan

1. Surgical procedure: Bilateral skin-sparing mastectomy (performed by breast surgical oncologist) with sentinel lymph node biopsy on the left, followed by immediate bilateral DIEP flap reconstruction with microsurgical anastomosis to internal mammary vessels
2. Intraoperative monitoring: Implantable Cook-Swartz Doppler placed on venous anastomosis for postoperative flap monitoring; ICG angiography to confirm flap perfusion
3. Postoperative care: ICU admission for first 24 hours with hourly flap checks (color, temperature, capillary refill, Doppler signal). Strict bed rest for 48 hours. Sequential compression devices and low-molecular-weight heparin for DVT prophylaxis. Abdominal binder for 6 weeks
4. Adjuvant therapy: Adjuvant endocrine therapy (aromatase inhibitor or tamoxifen) based on final surgical pathology. Radiation therapy if indicated by final pathology. Risk-reducing bilateral salpingo-oophorectomy recommended by age 35-40 (or after childbearing) given BRCA1 status
5. Secondary procedures: Nipple-areolar complex reconstruction with local flaps and tattooing planned 3-4 months after initial reconstruction. Possible fat grafting for contour refinement at 6-12 months
6. Follow-up: Microsurgery clinic at 1 week, 2 weeks, 6 weeks, 3 months, and 6 months postoperatively. Breast oncology surveillance per NCCN guidelines

Key Learning Points

• The DIEP flap preserves the rectus abdominis muscle and anterior rectus sheath, significantly reducing donor site morbidity (hernia, bulge, core weakness) compared to the traditional TRAM flap
• Preoperative CT angiography is essential for DIEP flap planning to identify the dominant perforators, map their intramuscular course, and plan the flap design
• The internal mammary vessels (typically the third rib interspace) are the preferred recipient vessels for DIEP flap breast reconstruction due to their reliable caliber and location
• Immediate autologous reconstruction does not delay adjuvant chemotherapy or radiation in most cases, and radiation can be delivered to the reconstructed breast, though it may affect the aesthetic outcome
• BRCA mutation carriers benefit from bilateral mastectomy with reconstruction, and autologous reconstruction provides a durable, lifelong result without the need for implant exchanges

All cases for this lecture as Markdown