Patient 65 Gallery

Before and after bilateral DIEP flap breast reconstruction in a 52 year old breast cancer survivor. She previously had undergone bilateral skin sparing mastectomy and tissue expander and implant reconstruction, followed by chemotherapy and radiation to her right chest wall. Unfortunately, her right implant failed and required removal due to implant infection and exposure, which is more common after radiation. She waited over a year before considering another attempt at breast reconstruction.

Given her very large abdominal overhang, she was an appropriate candidate for autogenous tissue reconstruction using her own tissue. She did not like the unnatural look of her left implant, which lay too low on her chest and put pressure on her ribs, creating chronic discomfort. Her goal was to look natural and proportional to her curves. Her left implant was removed and her pectoralis major muscles were returned to her chest wall. Bilateral DIEP flaps were used to microsurgically reconstruct her breasts. Her major postoperative risk was for slow wound healing at her abdominal donor site.

In patients who are very obese, their abdominal wall donor sites can have slow healing and wound breakdown at around one month after surgery. These wounds require packing with gauze and wound care to encourage slow healing on their own over many weeks to a month or longer in some cases. The final abdominal scar in these situations can heal indented or wider than other areas. If this is the case, an abdominal scar revision can be performed together with second stage procedures such as fat grafting and nipple-areolar reconstruction.

For this patient, this was exactly the situation for her. She packed her abdominal donor site wounds for around 4 weeks until they completely closed on their own. She waited a year to allow all swelling to go down and to feel ready for her final stage of reconstruction. She will plan to have nipple and areola reconstructions together with fat grafting to further improve her abdomen and surrounding areas at her final procedure. We are less concerned about wound healing problems as second stage surgeries than with the major free flap surgery as there is less tissue manipulation and less surgical swelling. Revising a scar involves removing it and closing the wound in several layers so that the indentation is corrected and all the layers of the abdominal wall lie in apposition to their respective layer on the other side – just like a three layer cake!

She is getting ready for her final surgery that will involve creation of new nipples and areolas, flap contouring using liposuction and scar revisions. Before that surgery, she wants to get as fit as possible and try to lose some weight on her own – which is something we always recommend before any elective procedure!