Practical Applications of Delayed-Immediate Autologous Breast Reconstruction: A Flexible and Safe Operative Strategy

Timing is an important consideration in patients undergoing mastectomy for breast cancer. While immediate reconstruction results in superior aesthetic outcomes, the need for postmastectomy radiation can often only be ascertained after review of surgical pathology. Delayed-immediate autologous reconstruction (DIAR) is a reconstructive approach that consists of mastectomy with tissue expander placement in the first stage and flap-based breast reconstruction in the second stage. We describe our institution's experience with DIAR to characterize the reasons in which patients opt for this reconstructive approach and analyze its ultimate outcomes.

We conducted an institutional review board-approved retrospective chart review of all consecutive patients undergoing DIAR performed by the senior author from 2007 to 2016. Data gathered included demographics, operative techniques, and postoperative outcomes.

In our study, 17 patients and 26 breasts underwent DIAR. Seven patients initially planned for and eventually underwent DIAR. Ten patients initially planned for implant-based reconstructions but ultimately underwent DIAR instead. Flap types included deep inferior epigastric perforator (n = 6), superficial inferior epigastric artery (n = 2), and muscle-sparing free transverse rectus abdominis myocutaneous (n = 18). The mean time between mastectomy and reconstruction was 208 days. Complications included tissue expander infection, vascular compromise, abscess formation, hematoma, and skin necrosis.

The delayed-immediate approach allows for breast reconstruction with aesthetic and psychosocial benefits, while enabling postmastectomy radiation in patients with advanced disease. We describe modifications to DIAR, including use of a flap skin paddle and prolonged time between stages, which allow for broader applicability. We show that DIAR accommodates a range of patient preferences with few complications.