Bilateral Free Flap Breast Reconstruction: A New Paradigm in Breast Cancer Therapy

Genetic testing and other advances in risk stratification for patients with breast cancer have led to a dramatic increase in the number of patients requesting prophylactic mastectomy. In women who are at high risk for developing breast cancer, prophylactic mastectomy has been shown to confer a risk reduction of 90 to 94%. The increase in prophylactic mastectomy has dramatically impacted the number of patients requiring bilateral autogenous breast reconstruction. Bilateral breast reconstruction after mastectomy presents multiple challenges with regard to flap selection. Many recent reports have advocated the use of the SIEA and DIEP flaps for autogenous unilateral breast reconstruction due to decreased abdominal wall morbidity; however, their use in bilateral reconstruction presents unique challenges.

The purpose of this study was to present a large single-surgeon experience with the use of muscle-sparing free TRAM, DIEP, and SIEA flaps for bilateral autogenous breast reconstruction. A retrospective chart review was performed of all patients presenting for bilateral autogenous breast reconstruction between 1993 and 2005. All patients underwent either bilateral prophylactic mastectomy or therapeutic and contralateral prophylactic mastectomy.

One hundred forty-two flaps were performed in 71 consecutive patients who presented for bilateral reconstruction. Of these, 112 were muscle-sparing free TRAM flaps (78%), 21 were DIEP flaps (14%), and 9 were SIEA flaps (6.3%). The median length of follow-up was 18 months (range: 6 to 72 months). The median patient age was 53 years (range: 42–70 years). The median follow-up was 24 months. The overall incidence of complications was low (9%). Two flaps required anastomotic revision in the immediate postoperative period for venous congestion. One (0.7%) flap sustained partial flap loss secondary to venous congestion. One (0.7%) flap sustained significant fat necrosis requiring revision. There was no incidence of complete flap loss, or abdominal wall complications such as hernia or bulging. One patient had recurrent abdominal seroma requiring office drainage.

This is the largest reported single-surgeon series presented for bilateral free flap breast reconstruction. Bilateral free flap breast reconstruction is both safe and clinically effective, with minimal complications. The authors conclude that bilateral free flap breast reconstruction remains an ideal reconstructive option for women requesting prophylactic mastectomy.