What is the typical waiting period after radiation for DIEP reconstruction?

Hello!  Thank you for your question.  After radiation, you have an increased rate of complications including wound problems, infections, thinning of the tissue, and decreased vascularity to the skin/tissue of the area.  The best method to reconstruct a breast following radiation therapy is with a flap.  The flap, which is skin, fat, and sometimes muscle, will serve to bring in healthy, well-vascularized tissue to the chest/breast area that will significantly ameliorate the radiation issues compounding the problem.  Microsurgical perforator flaps (such as the DIEP flap and SGAP/IGAP flap) are the newest and most-innovative procedures in breast reconstruction today.  As these are muscle-sparing flaps, the pain, morbidity, and complications such as those above, of these procedures are much less.  They are highly-complex procedures that few plastic surgeons performed and consult with one who is well-versed, trained, and skilled in these procedures if you are interested.  I would await 6-12 months post-radiation completion prior to consideration for definitive breast reconstruction.There are many options to breast reconstruction including implant-based and flap-based procedures.  The complication rate with implants following radiation is reported as high as 60-70% in some studies.  Flap reconstruction is usually recommended, but there are several centers who perform implants following radiation with great success and results.  I typically prefer flaps, such as the DIEP flap.  Typical complication discussed for the DIEP flap include: bleeding, infection, flap failure, fat necrosis, symmetry issues, abdominal bulge, etc.  Discuss the various complications, all rare, as well as success rate with your surgeon.  Other flaps are the conventional TRAM, latissimus flap, SGAP/IGAP, and, TUG.You are a candidate for other procedures, if you are willing to continue with your journey for a reconstructed breast.  Flaps such as those above, including others, are available.  The decision to continue with this will be your decision and what you are willing to go through.  There are risks and benefits with everything that we do in Surgery - discuss the various options with a board certified plastic surgeon who will educate you on all of the options and help you to decided if breast reconstruction or which procedure will be best for you.  Hope that this helps and best wishes!

After radiation, the skin of your right chest will never be quite the same. This makes some reconstructive choices not as good as others. Using your own tissue (from the abdomen, back or buttock) is often the better choice with less risk of complications when compared to implant-type reconstruction.  Many plastic surgeons wait a period of months after your last radiation treatment, and when considering DIEP flaps, studies show that the risk of flap complications is higher in the first six months. The main risk is your DIEP flap not being successful but this is rarely the case with an experienced surgeon. There are also risks associated with your abdominal donor site that are very similar to those of a tummy tuck. Find a plastic surgeon trained in reconstructive microsurgery and perforator flaps, they will be able to discuss ALL forms of breast reconstruction and can help guide you in the decision-making process.  

At least 4 months after the complete of radiation is a good rule of thumb. Implants should never be used alone in a radiated breast unless it is combined with another flap for coverage. To get more volume in a radiated field you need to use your own tissue. A TRAM flap is just one tool used in breast reconstruction. It sacrifices your stomach muscle but provides fat on a leash to your breast.. Another is a DIEP flap which also uses your belly tissue but does not sacrifice your stomach muscles. It essentially uses the same tissue that would be discarded in a tummy tuck but relocates the tissue to create a breast. A third option is the Latisimus flap (back muscle); its best use is along with an implant. These "autologous" tissue (your own tissue) can be used in any breast reconstruction. Women prefer it because it is their own tissue. It is also an excellent option for someone who has had radiation. You should consult with a plastic surgeon who offers all three of these methods as well as the implants, so that you have the best choice of options

The minimum you need to wait after radiation is 5-6 weeks, but most people wait at least six months to try and let the skin heal as much as possible.  The complications are most certainly higher after XRT, but it often depends on other factors such as your weight and other health issues.  

I typically wait until the acute changes in the skin have resolved, usually 4-6 months.  The shape of the reconstructed breast is often different from the opposite breast after radiation.  In addition, most patients will need some skin replaced with the flap, which can affect the appearance of the breast.  The radiated skin is often more swollen and firm to touch.  Wound healing complications in the breast are more common after radiation.

In many cases you have an redness that is present for several weeks after radiation.  If this resolves quickly and the skin is loose I would see you and see if you could have surgery earlier to use the remaining skin.  If the skin was sacrificed at the time of surgery then the timing can be decided up other factors.Three
basic forms of breast reconstruction exist. You can use your own tissue,
implants or a combination of the previous two techniques. Your own tissue can
be used in the form of the DIEP flap, PAP flap, SGAP flap or fat grafting.
Implants can be done in one stage or two stage. Two stage reconstructions are
started by placing expanders at the time of mastectomy. Once they expanders are
placed they are able to be inflated as determined by wound healing. The final
time consists of combining any of the above techniques.



If
you are interested in being seen in Austin please give us a call. I know
this is a difficult time for you. The majority of my practice is devoted
to reconstruction for women with breast cancer or who are BRCA+

Radiation may impact the vessels that are used when restoring blood supply to the DIEP flap in the chest.  There is no specific time that will make it perfect. usually you want any skin changes to subside. However, the vessels may not be good and one may not find out until the exploration of them.

I generally recommend autologous (using your own tissue) reconstruction after radiation therapy.  A DIEP flap is an excellent procedure.   I generally recommend waiting about 6 months after radiation to consider DIEP flap reconstruction.  If the radiation changes (redness or firmness of skin) persist at 6months, it is wise to wait longer - up to 12 months.   Please visit with a board certified plastic surgeon experienced with DIEP flap reconstruction to learn more about your options.

Dr. Basu

Houston, TX