DIEP Flap Reconstruction After Explant Surgery

Many of our patients have undergone prior bilateral mastectomy for breast cancer and are now faced with the tough decision of implant removal due to breast implant illness symptoms. Some of these patients elect to remain flat with an even, balanced incision closure after implant removal. Other patients, though, seek to achieve a natural breast reconstruction with DIEP flaps.

For patients who choose to proceed with a DIEP Flap procedure, one of the more challenging aspects of this decision is the sequence of surgeries’ timing. In other words, patients have to decide:

1. To remove implants, heal from their breast implant illness symptoms, and then consider a delayed DIEP flap breast reconstruction at a later date (often 3 – 6 months later); or
2. To combine both procedures as a single operation.

In our practice, we find that a larger proportion of our patients undergo combined en bloc removal (total capsulectomy) and a simultaneous DIEP flap breast reconstruction versus undergoing two separate surgeries separated by approximately 3 – 6 months.

Advantages of Combining Both Procedures

There are advantages to each approach. In combining the two surgeries, patients are placed under anesthesia only once. Combining the surgeries avoids two separate operations with two different recoveries. This is important because two recoveries often mean additional time off from work and time away from family.

Our Dual Surgeon Approach

Our practice is very comfortable with a combined en bloc removal and DIEP flap approach as Dr. Kocak and I perform the surgeries together. I often tell patients that Dr. Kocak is Left-Handed, and I am Right-Handed. As such, he typically performs the left-sided microsurgery, and I perform the right-sided one. We have developed a refined process with our dual surgeon approach to limit the operative time in combining these procedures.

Usually, I will begin removing the implant and the capsule simultaneously as Dr. Kocak is starting the DIEP flap surgery at the abdomen. Limiting the surgical time to approximately 6 hours plays an essential role in the patient’s recovery concerning potential postoperative complications like an infection. Our DIEP flap success rate is 99.4% after evaluating 300 consecutive patient cases over 18 months.

Combining the Surgeries is not for Everybody

For some patients, recovery from their breast implant illness-associated symptoms is paramount. Healing from BIAI allows patients to develop the physical, emotional, and mental reserve to proceed with a more extensive reconstruction utilizing their tissue.

We also had patients that have demonstrated subclinical infections with fungal/mold or bacterial organisms. In this setting, delaying the DIEP flap breast reconstruction can be an important consideration.

Coming Up with a Decision

From the perspective of the best cosmetic and reconstructive outcome, performing the DIEP flap breast reconstruction simultaneously as the implant removal allows us to optimize the skin envelope and utilize it as a component of the reconstruction.

The ability to use the additional pre-expanded skin and soft-tissue at the chest after implant removal also improves the reconstruction’s sensation. Using this skin and performing resensation surgery at the DIEP flap with additional nerve repair provides the best opportunity to reconstruct a normal feeling breast.

Ultimately, these two surgeries’ timing is an individual decision based on many factors and must be fully discussed with a microsurgeon who can perform both total capsulectomy and DIEP flap breast reconstruction.